Michel Tessier 12/31/22MIAMIBEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Serge Dominique Michel TESSIER DATE OF APPOINTMENT: 10-28-2021
BOARD/COMMITTEE: Disability Access Appointed byCommissioner Ricky ARRIOLA
FOR Scan ocANNER R CLERK STAFF
oLettteroffAppointment TERM END: /P/5/b>.TERM LIMIT: 3/c�), `-)
Scan o o Letter of Reappointment
0 oekter of Appointment/Reappointment a -m iled to C mittee Liaison on
Scan o 0 Boar and Committ Application (Completed on �
Scan o o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed
Scan o o Oath
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓ City Code Ordinance Section applicable to the agency, board or committee
RECEIVED ✓ 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
OCT 2 8 2021 amended through December 2010)
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
✓ Highlights of the Miami -Dade County Ethics Code
CITY OF MIAMI BEACH ✓ Sunshine Law and Public Records — Frequently Asked Questions
OFFICE or- THF CITY CLERK ✓ Memorandum - Solicitation by City Board and Committee Members
O Citywide Permit Application (Parking Department Form)
O Booklet — Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan O O Source of Income Statement
Scan O O Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REE/PORTING e p COPY in file and ORIGINAL for Annual Report.
Received on: 10-28-2021 Signed by
2Date -a o C e
Processed on:�/ ® r / By Employee:
Date l It ' s ice Staff Initi
Scanned on: /0 d ? / r / BY Employee: Em to ee:
Date City I Office St Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan O
Resignation Letter
Date Processed
Initials Scan O
Removal Letter due to absences
Date processed
Initials Scan O
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are committed to providing exceilent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
MIAMIBEACH
City of Miami Beath, 1700 Convention Censer Drive, Miami Beach, Florida 33139 www.miamibcachll.gov
OFFICE Of THE CITY CLERK, Wool E. Granodo, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClo.rk@mlamibemhfl.gov
October 28, 2021
Mr. Michel Tessier
1665 Bay Road Unit 325
Miami Beach, Florida 33139
RE: Disability Access Committee
Dear Mr. Michel Tessier:
Congratulations! You have been appointed by Commissioner Ricky Arriola to the above -referenced
Board or Committee, for a term ending: 12/31/2022.
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.
Regar s,
1'-4
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Valeria Mejia, 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
City of Miarni Beach, I/or)x; r,1 , I1�,, ',�s;��s� I�. , €:,, it )r,;ir�a ;3: 1 YI.� 1;rfk�_._.I rr�.
Of { K'f €X- if if. (IFY CINW, R(ifad F. Grvanod<>;
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MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(a)miamibeachfLgov
Telephone: 305.673.741 1
STATE OF FLORIDA
COUNTY OF MIAMI DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
❑X I am a resident of the City of Miami Beach for six months or longer.
❑ I have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
❑ I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
Signature
Serge Dominique Michel Tessier
Printed Name
NOTARY
Date
10-28-2021
Sworn to (or affirmed) and subscribed before me, by means of Vnhysical presence or El online
notarization, this�0 day of ® O 20� by
1/ fi�ss� �
,)r,—<i-l? v�ib/✓fA u UC All /NV' IN of Miami Beach Board/Committee Member).
Produced ID !�/P,
Form of Identification
�rs n y K
Sign re of tary Public
Name of Notary, Typed, Printed, or Stamped
C-4
(NOTARY SEAL)
�gZt.RYCharles J. gs�Oc� NOTARY PUBLIC
'n
7-g STATE OF FLORIDA
= Comm# GG168171
s�NCE A, Expires 12/14/2021
1
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: 13C(a)miamibeachfI..qov
Telephone: 305.673.741 1
TESSIER
Last Name
DIVERSITY STATISTICS REPORT
Serge Dominique Michel
First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. It is being
asked to comply with City diversity reporting requirements.
Gender:
Male
Female
Other
�9 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
F-1 African American/Black
ED Asian or Pacific Islander
ID Caucasian/White
Native American/American Indian
Other — Print Race:
�j I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
No
I prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
No
I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeochfl.gov
OFFICE OF THE CITY CLERK
Email: 13C(a)miamibeachf1.gov
Telephone: 305.673.741 1
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
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(1) (2)
TESSIER Serge Dominique Michel
Last Name
First Name
Middle Initial
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.
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;" or
2. A "Statement of Financial Interests (Form 1)1;" or
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.
c4� 10-28-2021
Signature re Date
Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami -Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
'
""Mi®DADS SOURCE OF INCOME STATEMENT Clear From Print Form
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 I Last Name
First Name Middle Namellnitial
2020 ITIESSIER Serge Dominque Michel
Mailing Address — Street Number, Street Name, or P.O. Box
1665 Bay Road Apt 325
City, State, Zip
Miami Beach, FL, 33139
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 hoe.
Filing as an Employee (check one)
County ® Public Health Trust Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began on/ended on
Filing as a Board Member (check one)
County ® Municipal:
(Municipality)
Board where serving
Alternate address (if home address is exempt) Work telephone Term began on/ended on
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 for 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
Address
Description of the Principal Business Activity
Atelier Tessier Inc
1665 Bay Road #325
Mffiami Beach, FL, 3.3139
Consulting
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
10-28-2021
Date signed
RECEIVED BY ELECPJ(Lfttlj�L.J
❑ Hardcopy
❑ Electronic CIR T 2 8 2021
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS NOT honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage (G7) access.
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permit". In order to avoid
any unnecessary enforcement actions, it is important that our records reflect the most current and
accurate information regarding your vehicle license plate. Inaccurate and/or outdated vehicle
information may lead to the issuance of parking citation(s) and/or the towing of your vehicle.
Please note that this new access card CANNOT be hole -punched or perforated in any manner. To use
the new card please hold the card at close proximity to the reader until the gate opens. You may need
to try the other side of the card. Please ensure you hold the entire surface of the card against the reader
until the gate opens.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Bnard Memhar Infnrmntinn
Date of Application: 10-28-2021
Applicant Name:
Board/Committee Name:
Disability Access Committee
Address: 1665 Bay Road apt 325 Miami Beach , FL, 33139
E -Mail Address:
michel@tessier.biz
Work Phone:
Home Phone
Cell Phone: 786.247.7769
Preferred Contact Method: Text message
Vah; IP_ Infnrmntinn
Tag: JMWR52
Color:
BLACK
State: FLORIDA
Year:
2021
Make: JEEP
Model:
COMPASS
Applicant signature: ,K
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2°' floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkinaReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION — APPLICANT NAME
Pnriirinen nonnrFrmwn• Cnrlinn
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature: -9
Signature: -9
Date Issued:
Date Completed: