Harvey Burstein 12/31/23B O A R D A N D C O M M ITT E E C H E C K L IS T
arrowreee/1FY/ 'é"" Are or Arronrwevr
BOARD/COMMITTEE: //f' Appointed by. __5y e ANp2
Cone f"« ge21.. o. val ,7
• teter ot Rearoiotmemt 3l3j ', [3"1 /'f" omamenveaoomoent e.m9 e@_ o, correé 'íá6o 6o -iá de reno corres_y2//$/2/
• Resume.curcutum vtae f)/)/2 / o Diversity Statistics Reporting (Completed on_1 ye _)
o Oath 7
'2-2/-2/
F O R S C A N N E R
Scan o
Scan o
Scan o
Scan o
Scan o
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
City Code Ordinance Section applicable to the agency, board or committee
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
amended through December 2010)
✓Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
✓Sunshine Law and Public Records - Frequently Asked Questions
(IT O F M IAM I B E A C H / Memorandum - Solicitation by City Board and Committee Members
OFFICE OF THE CITY CLERK
RECEIVED
JAN 4 2022
Scan O
Scan o
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
Received on:
Scanned on:
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING êp C O P Y in fil e an d O R IG IN A L fo r A nn ual Repo rt
/29-2, X•52-
L
~ ~,
1
;J- Signed by ZU.· ~-<-~-e_,
Processed on:_..,._...Jí_!_.___-'- By Employee: --t-:r-:ñ-<-.:----,,--------------,----
1/-J uf/ª}~
...,._,,,.f--,__-t--+-+~--~----BY Employee: ---+-+-:h,£-----,9'--f::,,,--<"------------
Date
CO NCLUDED & 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:CLERBOARD AND COMMITTIES DATABASE\CHECKUST MASTER\B&C Checklist 2015 MASTERdocx
MLAA MIBEA CH
City of Miami Beach, 1ZOO Convention Canter Drive, Miami Pooch, Horida 33 139 yyyy_miamibc_a chf_ga
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fox. 305.673.7254
Email: CiyClerk @miamibeachfl.gov
December 21, 2021
Mr. Harvey Burstein
1775 Washington Ave PH2
Miami Beach, Florida 33139
SUBJECT: Disability Access Committee
Congratulations! You have been reappointed by Commissioner Alex Fernandez to the above
referenced, board or committee named above, for a term ending. 12/31/2023.
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. 7 411. Please read the enclosed materials carefully.
Congratulations and good luck.
7
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Valeria Mejia, City Liaison
ATTACHMENTS:
Letter of Appointment
Oath
City Code/Ordinance section applicable to agency, board or committee
City Code Section 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 Ordinance
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
+,A //E A CH [\/\ [f \/À H, ]
f é i É ; ft he wee
City of Miami Beach, 'K O Comrn ton Corks Drive, Mam Bo uch, Hlotu da 3313/ y2ye¿_Iuig__L. .g_hi_y
OFKCE O TH CIIY CAERK Rafal E. Granado, Ci#y Clerk
1al: 305 6737l1, Fac 305.673.7254
Emoil . CityC led@miam ibeoc.h f.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Harvey Burstein
RE: Disability Access 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: 12/31/2023.
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 0f 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 wh ich I serve) on July 1st, following the closing
of the calendar year on which I have served. /
//' .·-)·. .,'~ .f --
,'
-Mr. Harvey Burstein
Sworn to and subscribed before me th· ~ ,0- s
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.
!
} i
City of Miami Beach
I700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
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
(),all that appl y ).
Á-- I am a resident of the City of Miami Beach for six months or longer.
Home Address l1) l shp ,t ue )
a 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).
Name of Business _
P S,/[es,, J(Sf@S,
u 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).
Name of Business _
[[us/fess (ddfeS5
"O wners hip 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" m eans any sole pro prietorship, sponsorship, corp oration, limited liability company, or other
entity or business association.
Under penaltie of erjury, I declare that I have read the foregoing document and that the facts stated in it
are true. y /o.y-= h. _ A2/
Sig n; Ire • Date oyy E le _
Printed Name
NOTARY
sw or n to (or affiped) and subscribed before me, by means of s physical presence or e onlne n0a7a97
s2,b)ce..l • 2,. Hi t, lKS7to
(City of Miami '}yach Board/Comz:e Member). X esso [ b)al/ere yese
Form of Identification
Personally Known
Signature of Notary Public
.±., CHARLES J. DAGOSTIN
/f1ë'.t'f~R~yt ~SS ION # HH 165705
;; ¿;i EXPI RES: December 14, 2025
%..é oded mr u Notary Pub lic Underwrit ers %£.%°
2 r r two otrt.rt.rv I V
Section 2-11.1() of the County Ethics Code requires that certain employees and public officials file a finan cial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending [Last Name First Mame
a0zo ] Su// Hl
1-------------'---'"--"''----=----------I Mailing Address - Street Number, Street Name, or P.O. Box f)
li7_ ldso rx /lue l
Middle Namellnitial
7
City, State, Zip . ¡)
} t (a w Leac h t 327
lf your home address is your mailing address, and your home address is exem pt from public records pursuant to Fla. Stat $119.07. read
instructions on the following page and check tlele.
Filing as an Employee (check one)
O County I] Public Health Trust [] Municipal:
(Municipality)
Departm ent
Position or Title Employee ID Number
Work address l Work telephone Employment began on/ended on
I ¡
Filing as a Board Member (check one)
[J county Eiíonteia: (io Bat
(Municipality)
Board where serving DA
Alternate address (if home address is exempt) [Work telephone 1 Term began on/ended on
\7 315 1//-
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. []
i Name of Source of Income Address Description of the Principal Business Activity 3
Sa cr I cc , lt~ 6od
172. As»o,+>d 0-
14s7 pp- IR r
3 , _7 U -&d /4so y/ A»- i ao e7 o l ·te , -7 ?i
I hereby swear (or affir „
{ A ... '
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
HardcoPYpECEIVED
Electronic Cöjy
JAN 4 2022
C ity o f M ia m i B e a c h
1700 Convention Center Drive
Mi ami Beach, Florida 33139
wwwmigmibeacht]_gov
OFFICE OF THE CITY CLERK
Email: BC@m a mbe ach f]_go
Telephone: 305 .673 .74 11
DI V ERSI T Y STA TI S TI C S RE POR I
/hey,
Last Name 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:
guae
D Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asían or Pacific Islander
El.Caucasi an/whi te
[]N ative American/American Indian O Other- Print Race: _
D I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
J Yes
lNo
D I prefer not to answer.
Do you consider yourself Physically Disabled?
lves
~'No
O I prefer not to answer this question.
Page 6 of6 -- - - - . - - .. ---
/ A {[A A IL2L At ' HIYVVIE [VVJ BO/KD & OMMIHIEL
t 'if+j it 1
can, .r ow ea. +kkks eek«no«or PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph:. (305) 673-7505 or (305) 673-7000 et. 6200
v
La
PARKING
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 rellect 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 cord. 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.
Board Member Information
Date of Application: 12-23 2
Applicant Name: [[[pp4} j [3sen'
Board/Com mittee Name: P,/1c
Address: li7 0shoot0.Ave
E Mail Address: 1utei) o) G ru ov
Work Phone:
Cell Phone:
Home Phone
Preferred Contact Method:
Vehicle Information
Tog: X OOY Color: de
State: H=LA Year: 0
Make: tous Model: e 3o
Applicant Sianature:
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: ParkingReception@miamibeachfl,gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION -- APPLICANT NAME
P, ·k' D ari mna epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #
Issued By Print Nome: Print Name.
Signature:. Signature:
Dote lssued: Date Completed:
s
«4fi: t · 9 ' ' · .. q gr,,uu z o·-·
2
·
· ' ' . .
, : g
'
-
u»
¢
. ~
·. '' . '' !
.
il
« . . .A:
+ t
: .. ' . ·. . . . . . ~ I .. - .
~. . ·)
' '
a '
- 5
.. ,
- 4
. ·.··:
. . •.. :. ~ .
: . ' . . .
$i ",
;
· .... _ . ·:- : ..
' "
£ E
.. ',{ .. ' I .