Baruch Jacobs Application PackageJacobs M.D.BaruchNAME:
Last Name First Name Middle Initial
3605 Flamingo Dr Miami BeachHOME ADDRESS:
Apt No.Home No./Street City
Florida 33140
State Zip Code
(305) 674-0631 (305) 674-8586PHONE:
Home Work
drjacobs@miamibeachplasticsurgery.com
Email Address
Miami Beach
Street
400 Arthur Godfrey Rd #305
City
Florida
State
33140-
Zip Code
Address:
MB Cosmetic and Plastic Surgery Center Position:Business Name:Doctor
Pursuant to City Code section 2-22(4) a and 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.
Yes● Resident of Miami Beach for a minimum of six (6) months
● Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months:
● Are you a registered voter in Miami Beach:
● (Please circle one): I am now a resident of:
● I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
● Are you presently a registered lobbyist with the City of Miami Beach?
Yes
Yes
Middle Beach
No
Medical, Resident for 30+ years
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 City Clerk’s Office. (Regular Boards of City)
Choice 1:
Choice 2:
Choice 3:
Transportation, Parking and Bicycle-Pedestrian Facilities Committee
No2. Present participation in Youth Center activities by your children
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board:
No Years of Service:
ages, and which programs. List below:
if yes, please list the names of your children, their
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
* 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
_______________________
Child Name Age Program
No● Have you ever been convicted of a felony:If yes, please explain in detail:
● Do you currently have a violation(s) of City of Miami Beach codes:No If yes, please explain in detail:
● Do you currently owe the City of Miami Beach any money:No If yes, please explain in detail:
● Are you currently serving on any City Boards or Committees:No If yes, which board?
● What organizations in the City of Miami Beach do you currently hold membership in?
● List all properties owned or have an interest in, which are located within the City of Miami Beach:
Property
3605 Flamingo Dr
● I am now employed by the city of Miami Beach:
No Which department?
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 federal equal opportunity reporting requirements.
MaleGender:
Physically Challenged:No
White
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself to be.
Other Description:
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino.No
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
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 board/committee you have served on for period of one year after leaving office (Miami
Beach Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: 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).
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 have received, read and will abide by Chapter 2, Article
VII – of the City Code “Standards of Conduct for City Officers, Employees and Agency Members.”
I Baruch Jacobs M.D. agreed to the following terms on 3/5/2020 12:52:16 PM
Received in the City Clerk's Office by:
Name of Deputy Clerk
Control No.
Date
CURRICULUM VITAE
NAME: Baruch Jacobs, M.D., F.A.C.S.
ADDRESS: 400 Arthur Godfrey Road
Miami Beach, Florida 33140
TELEPHONE: (305) 674-8586
DATE OF BIRTH: November 16, l956
PLACE OF BIRTH: New York, New York
APPOINTMENTS: Chief, Division of Plastic Surgery (1996-1999)
Miami Heart Institute
Miami Beach, Florida
Clinical Instructor (1995 – 2016)
University of Miami School of Medicine
Miami, Florida
Adjunct Staff (2000-Present)
The Cleveland Clinic Foundation
Cleveland, OH
Mount Sinai Medical Center (1990-Present)
Miami Beach, Florida
Baptist Hospital (1991-2003)
Miami, Florida
South Miami Hospital (1990-2003)
South Miami, Florida
HealthSouth Doctors Hospital (1990-)
Miami, Florida
EDUCATION: B.S., Summa Cum Laude, C.C.N.Y. (1977)
M.D., NYU School of Medicine (1981)
RESIDENCY: Junior Surgical Resident
Maimonides Medical Center (1981-1983)
Senior Surgical Resident
Boston University Medical Center (1983-1986)
Chief Surgical Resident
Boston University Medical Center
(1986-1987)
Plastic Surgery Resident
The Cleveland Clinic Foundation
(l987-l989)
Aesthetic Plastic Surgery Fellow
Lawrence B. Robbins, M.D.
Miami, Florida (March, l989)
Thomas J. Baker, M.D.
Miami, Florida (April, l989)
Manhattan Eye, Ear and Throat Hospital
New York, N.Y. (May, l989)
Hand Surgery Fellow
The Cleveland CLinic Foundation
(September, l989 - December, l989)
LICENSURE: New York (1982 - 1984)
Massachusetts (l983 – 1988)
Ohio (l987 - 1990)
Florida (l989 - )
CERTIFICATION: American Board of Surgery (l988)
American Board of Plastic Surgery (1992)
MEMBERSHIPS: Diplomate, National Board of Medical
Examiners (1982)
Fellow American College of Surgeons (1982-
) American Society of Plastic Surgeons (1987 -
)
Miami Society of Plastic Surgeons (1990- )
Massachusetts Medical Society (l983)
American Medical Association (1983)
Cleveland Academy of Medicine (1987)
Ohio State Medical Association (1987)
American Cleft Palate - Cranio-facial
Association (l989)
Florida Medical Association (1989)
HONORS: Phi Beta Kappa (l977)
Dean's List (l973-l977)
New York State Regents Scholar (l973-l977)
Graduated with Honors in Biology and
Chemistry
for Independent Research (1977)
Summa Cum Laude (l977)
COMMITTEES: Ethics Committee, South Miami Hospital
(1991-1992)
Surgical Case Reveiw Committee, Miami Heart
Institute (1992-1999)
ER Committee Miami Heart Institute (1993-
1996)
Ambulatory Services Committee, Mount Sinai
Medical Center (1993-1995)
Operating Room Committee, Mount Sinai Medical
Center, (1997-1999)