Loading...
Brenda Chemtov 12/31/18J\/\J BEACh BOARDS AND COMMITTEE CHECKLIST APPOINTEE: ,kern ( 1`e 44- oV DATE OF APPOINTMENT: 3/1 //r BOARD/COMMITTEE: /4_,,,,.A.)-- --(, � ')- (X44"1 ?1' Appointed by: /444 11�/l ke- FOR SCANNER FOR CLERK STAFF l_ �k---� 1/ Scan o o Letter of Appointment TERM END: - ''�� -'PERM MITf'`"l _ Scan o o Letter of Reappointment �� � � Te7M Z -1;f4 dT o o iy ., etter of Appointment/Reappo4n S mailed to Committee Liaison on Scan o Scan 0 Scan o o Board and Committee Application (Completed on o Resume/Curriculum Vitae o Diversity Statistics Reporting (Completed on o Oath £.. ;,: IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK .=u ✓ City Code Ordinance Section applicable to the agency, board or committee L.24 <U V City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 ' ✓ County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as rc3 amended through December 2010) LW CV <w V Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) 0 "' zit ✓ Highlights of the Miami -Dade County Ethics Code LUacc ✓ Sunshine Law and Public Records — Frequently Asked Questions Z_" ,7 Memorandum - Solicitation by City Board and Committee Members a, o` c's cv Scan 0 Scan 0 Received on: Processed on: Scanned on: o Citywide Permit Application (Parking Department Form) o Booklet — Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees o Source of Income Statement o Acknowledgment of Financial Disclosure Requirement C DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report. '�� Signed by X 'L, 3-(01-I(-6 Date Date Date By Employee: By Employee: 7F3ar or Committee M Ci -rk's Office Staff Initials ity k's Office Staff Initials CONCLUDED & RESIGNATION LETTERS Term Expired Letter Resignation Letter Removal Letter due to absences Date Processed Initials Date Processed Date processed Scan 0 Initials Scan 0 Initials Scan 0 F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx n and d hi.,fo,. CC'rf10.. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov March 02, 2018 Ms. Brenda Chemtov RE: Audit Committee Dear Ms. Brenda Chemtov: Congratulations! You have been appointed by Mayor Dan Gelber to the above -referenced Board or Committee, fora term ending: 12/31/2018. Pursuant to City of Miami Beach Code Section 2-22 (5)a: Notwithstanding any other provision of the City Code or of any Resolution, commencing with terms beginning on or after January 1, 2007, the term of every board member who is directly appointed by a member of the City Commission shall automatically expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or upon the appointment/election of the successor City Commission member. If you are unable to accept this appointment, or have any questions, please call the Office of the City Clerk at 305.673.7411. Please read the enclosed materials carefully as they concern your duties, responsibilities, and requirements as a board or committee member. Congratulations again and good luck. ity Clerk 4 cc: Saul Frances, Parking Director Mark Coolidge, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements City Code/Ordinance section applicable to agency, board or committee City Code Sections 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 Ordinance No. 2006-3543 - Amendment to City Code Section 2-22 Miami -Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics City Wide Permit Application - (Parking Department Form) Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov Oath of Office Oath of Civility and Acknowledgements TO: Ms. Brenda Chemtov RE: Audit Committee I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the United States, the State of Florida, and the City of Miami Beach, and to perform all the duties of a member of the above-mentioned board or committee of the City of Miami Beach to which I have been appointed for a term ending: 12/31/2018. To my colleagues and to all of those I represent and serve, I pledge fairness, integrity and civility, in all actions taken and all communications made by me as a public servant. I have been issued a copy of section 2-11.1 of the Miami -Dade County Code (Conflict of Interest and Code of Ethics Ordinance), as well as Florida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers and understand that as a member of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure* requirements of Miami -Dade County or the State of Florida (depending on the board or committee on which I serve) on July 1st, following the closing of the calendar year on which I have served. 4' 0,,L, Ms. Brenda Chemtov Sworn to and subscribed before me this day of/I/I/#/4,2018 L/Ch r -s D'Agostin eputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov CITY CLERK'S OFFICE CityClerk@miamibeachfl.gov Telephone: 305.673.7411 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami - Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member's Name: rie/vk I understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami -Dade County Financial Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must file, even though they may have been recently appointed. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. 1. A "Source of Income Statement" 2. A "Statement of Financial Interests (Form 1)" 3. A Copy of your latest Federal Income Tax Return Failure to file one of these forms, pursuant to the Miami -Dade County Code, may subject the person to a fine of no more than $500, 60 days in jail or both. Signature Updated: Thursday, December 28, 2017 Page 4 of 4 F:\CLER\BALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx 3) IPI/ Date SOURCE OF INCOME STATEMENT Section 2-11.1(i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st of every year. Disclosure for Tax Year Ending Last Name As* 0201-7 CiLic-/-rriAr Mailing Address — Street Number Street Name, or P.O. Box gO l iSIS,-)s 9Mv'e City, State, Zip ('^uftMA 6I-Pr—Pr First Name Middle Name/Initial 33)39' If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. §119.07, read instructions on the following page and check here. ❑ Filingan Employee (check one) County - Public Health Trust fl Municipal: Department (Municipality) Position or Title Employee lD Number Work address Work to a Employment began on/ended on )ZMuniclpal: 1.Olt Cr( ( (Municipality) Filing as a Board Member (check one) 0 County Board where serving PU.D1 ( rT �= L Alternate address (if home address is exempt) Work telephone - (Term b gan on/ended on .D'DI� List below every source of income you received, along with the address and the principal activity of each source. include your public salary.'Place the sources of income in descending order, with the largest source first. Examples of sources of income include: compensation for services, income from business, gains from property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also; include any source of income received by another person far your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.❑ Name of Source of Income 1 Address 5-1-f91.UD -01-'-✓L m4 -�'Sr ILO\ WA-scr tib W'J �9v� 1.1 3331 Description of the Principal Business Activity AKSi .5-Jat 1 1 5 JLe I hereby swear (or affirm) that the information above is a true and correct statement. Signature of Person Disclosing 31Ig--I15 Date signed RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy Electronic -Copy OFFICE1 USE ONLY Accepted: Y / N Deficiency: 138_SP-14 C0E 2016 Processed Date/Initials: Scanned Date/Initials: MINA BEACH Name: DIVERSITY STATISTICS REPORTING c?),LaA014-- Board / Committee: Appointment Date: D-0 i `' Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually prepare and present a report to the City Commission identifying the City's diversity statistics. This form allows board and committee applicants and members to voluntarily self -identify their race, ethnicity, disabled status and gender. Please check the appropriate box for each category: Gender: Male Li Female-. Race/Ethnic Categories What is your race? 0.African-American/Black Caucasian/White 0 Asian or Pacific Islander 1-1 Native-American/American Indian L.J Other – Print Race: Do you consider yourself to be Spanish, Hispanic or Latins/a? Mer the "No" btv not Spanish, Hispanic, Latino/a. ,No 0 Yes Do you consider yourself Physically Disabled? .Nc 0 Yes C:Wse.rs\CFNTFraN\AppD tai! ocaF,Ptlic r "'�'�lir o.,,,, en o an; ifs r O fi • a, ^r, L a � QSpii+a d�. �lr,. :D f;, interne': r'l.c.'1C.�Jni:, `1 t. i,.0 Qt7k�Ni-'�-..�� �,i�;titi> > ti Irl, information form 05.20-15 FfNAL.doc Updated: Monday, January 26. 2015 MIAMI BEACH c�rw Last Name t.;. Home Address ,tJS 124_ S 3.1 -c3 ,v (is Home Telephone Business Name Work Telephone zmiA. First Name BOARD AND COMMITTEE APPLICATION FORM Middle Initial -33 k3 Zip Code City State Cellular Telephone Occupation Email address Business Address City State Professional License (describe): Expires: Please attach a copy of currently effective professional license. Pursuant to City Code section 2-22(4)a & b: Members of agencies, boards and committees shall be affiliated with the City. This requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the City for a minimum of six months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a business established in the City for a minimum of six months. • Resident of Miami Beach for a minimum of six (6) months: Yes or No Zi • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes or No • Are you a registered voter in Miami Beach: Yes: or No IZt • I am now a resident of: North Beach South BeachMiddle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: Zip Code • Are you presently a registered lobbyist with the City of Miami Beach? Yes Zi or No Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the Office of the City Clerk. ❑ Affordable Housing Advisory Committee 111.in Public Places Committee dit Committee ❑ Board of Adjustment ** ❑ Budget Advisory Committee 0 Committee on the Homeless ❑ Committee for Quality Education in MB 0 Convention Center Advisory Board 0 Cultural Arts Council ❑ Design Review Board' 0 Disability Access Committee ❑ Health Advisory Committee 0 Health Facilities Authority Board ❑ Hispanic Affairs Committee ❑ Historic Preservation Board* ❑ Housing Authority ❑ Human Rights Committee ❑ LGBT Advisory Committee ❑ Marine & Waterfront Protection Authority ❑ Miami Beach Commission for Women 0 Normandy Shores Local Government Neighborhood Improvement 0 Parks and Recreation Facilities Board eO 0 Personnel Board 0 Planning Board** ❑ Police Citizens Relations Committee ❑ Production Industry Council ❑ Sister Cities Program 0 Sustainability Committee ❑ Transportation, Parking, & Bicycle -Pedestrian Facilities Committee 0 Visitor and Convention Authority ❑ Youth Commission * Board members are required to file Form 1 — "Statement of Financial Interest" with the State. *If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, Design Review Board, Historic Preservation Board or Planning Board, attach a copy of your currently -effectively license, and furnish the following information: Type of Professional License License Number License Issuance Date License Expiration Date Page 1 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx °O Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with the Scott Rakow Youth Center and/or the North Shore Parks Youth Center: Ivi • Please describe your past service with the City's Youth Centers (include dates of service): • Present participation in Youth Center activities by your children: Yes No If yes, please list below the names of your children, their ages and the programs in which they participate: Child's name: Child's name: Age: Program: Age: Program: • Have you ever been convicted of a felony? Yes rZi or No C4 If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach Code? Yes or N If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money? Yes or No)N3 If yes, explain in detail: • Are you currently serving on any City Board or Committee? Yes Zi or N If yes, which board/committee? • In what organization(s) in the City of Miami Beach do you currently hold membership? Name Position Name Position • List all properties owned or in which you have an interest within the City of Miami Beach: go N. N-r6o s OL, r -t8 f 3& 33E • Are you now employed by the City of Miami Beach? Yes LZI or No Which department and title? • Pursuant to City Code Section 2-25 (to): Do you have a parent , spouse , child brother or sister who is employed by the City of Miami Beach? Yes L,Jor No If "Yes," identify person(s) and department(s): The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is being asked to comply with City diversity reporting requirements. Gender: Male Female Race/Ethnic Categories What is your race? African-American/Black lar Caucasian/White Asian or Pacific Islander izt Native-American/American Indian Page 2 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a. 4SiNo Yes Do you consider yourself Physically Disabled? +No LJ Yes NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO: o Prohibition from directly or indirectly lobbying City personnel (Miami Beach City Code section 2-459). o Prohibition from contracting with the City (Miami -Dade County Code section 2-11.1). o Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office (Miami Beach City Code section 2-26). o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1). o CMB Community Development Advisory Committee: prohibition, during tenure and for one year after leaving office, from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom you have business or immediate family ties (CFR 570.611). o Sunshine Law - Florida's Government -in -the -Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of boards, commissions and other governing bodies of state and local governmental agencies or authorities. o Voting conflict — Form 8B is for use by any person serving at the county, city or other local level of government on an appointed or elected board, council, commission, authority or committee. It applies equally to members of advisory and non -advisory bodies who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes. Upon request, copies of these laws may be obtained from the City Clerk. I HEREBY ATTEST TO THE ACCURACY AND TRUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, READ AND WILL ABIDE BY CHAPTER 2, ARTICLE VII, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY." Applicant's Signature 1P,1I(d Dafe Received in the Office of the City Clerk by: Cti 1-1A1 Name of Applicant (PLEASE PRINT) lelo) IC U Name of Deputy Clerk s Control No. 7/ Date ATTACH A CURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY APPLICABLE PROFESSIONAL LICENSE. ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED INFORMATION. Page 3 of 4 C:\Users\CLERQueR\Desktop\BC APPLICATION.docx