Harvey Burstein 12.31.23BOARD AND COMMITTEE CHECKLIST
APPOINTEE:
Harvey J. Burstein DATE OF APPOINTMENT: Jan 10, 2023
BOARD/COMMITTEE:
Transportation Appointed by: Commissioner Fernandez
FOR SCANNER FOR CLERK STAFF $ , , 3113
Scan o o Letter of Appointment TERM EN1): R_.3_J_ i t;=.FSM ImIMIT. (
Scan 0 0 Letter of Reappointment
o/&ody
of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan o 0d ommittee Application (Completed on )
Scan o o Resum6/Curriculum Vitae ��
o Diversity Statistics Reporting (Completed on Com3'
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
amended through December 2010)
,IAN 10 2023 ✓ 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 nr THE CITY CLERK Memorandum - Solicitation by City Board and Committee Members
Scan o
Scan o
Received 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
o Board and Committees Liaison Responsibilities
O DIVERSITY STATISTICS
Jan 10, 2023
Date
Jan 10, 2023
Processed on:
Date
Jan 10, 2023
Scanned on:
Date
Signed by
By Employee:
By Employee:
GINAL for Annual Report.
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
MIAMBEACH
City of Miami Reach, 3 700 Convention C nnik7r fkivca, Mmmi 13oo�h, f=lurid a 3 3 139 wwo^ .miamibo achi .€a -fv
OFFKT. Of THE C FT1` C=LERIC, RnfGal F. Gr€an+ado, City Clerk
Tel: 30 ,673.74.1 T, Fax 36,5.673.724
Emil: Cjtyc1L k,@miamibPw.hfi gay
January 10, 2023
Mr. Harvey Burstein
1775 Washington Ave PH2
Miami Beach, Florida 33139
RE: Transportation, Parking and Bicycle -Pedestrian Facilities Committee
Dear Mr. Harvey Burstein:
Congratulations! You have been appointed by Commissioner Alex Fernandez to the above -referenced
Board or Committee, 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 305.673.7411.
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.
Reg
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Monica Beltran, 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
NMAMIBEACH
City of Miami Beath; I /00(,orr,onikt n Cbntet D ivp, Mcami Boac a, T1aMu3139 %^ wrniarnih achffl.g
OFFICE C* THE CITY CLERK, Rrafoal E. Granado, City cork.
T& 305-673.7111, Fox. 305.673,72 54
Ein ail: CTIyCIerk@srjieam hfl gny
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Harvey Burstein
RE: Transportation, Parking and Bicycle -Pedestrian Facilities Committee
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.
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 1 st following the closing
of the calendar year on which I have served.
Mr1 Hal`iev Burstein
Sworn to and subscribed before me this,. Lo day of _/ 2023
Ch 6s D'Agost
,Deputy 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.
M I AAA I B EAC 1 S
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCO)miamibeachff.gov
Telephone: 305.673.741 1
RECEIVED
JAN 10 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
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 apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 1775 Washington Ave. PH 2, Miami Beach, 33139
p 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
Business Address
p 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
Business Address
"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 penal ' of per ury, I declare that I have read the foregoing document and that the facts stated in it
are ru . ` Jan 10, 2023
Signat re Date
Harvey J. Burstein
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means ofphysical presence or o online notarization,
this day of )&l ti _ 20 Z J by r i�rn
(City of Miami Beach Board/Committee Member).
I/ Produced ID f-- I- T)L .
Fo" of Identific ibn
Personally Kn
Siqnature of Notary Public
CARL MICHAEL ANTON VIDEN
$~4T_ Notary Public, State of Florida
Commission# HH 180881
My comm. expires Sept. 30, 2025
(NOTARY SEAL)
,M, I /\A I B EAC F-1
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfi.gov
OFFICE OF THE CITY CLERK
Email: B_ as rniamibeachfl.gov
Telephone: 305.673.741 1
DIVERSITY STATISTICS REPORT
Burstein Harvey J.
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:
0 Male
0 Female
Other
F --j I prefer not to answer.
Race/Ethnic Categories:
What is your race?
El African American/Black
0 Asian or Pacific Islander
Caucasian/White
j Native American/American Indian
0 Other — Print Race:
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
IZI No
I prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
No
1 prefer not to answer this question.
Page 6 of 6
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www,miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.741 1
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)
Burstein Harvey J.
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.
.Qjlg 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 fil f these forms, pursuant to the Miami -Dade County Code, may subject the person to a fine
of no m$50 , 0 days in jail, or both.
r o/�� 3
n re J 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
C-%ri COMAI I \DCI_\D/IADn Akin /`nRARAITTCC ADDI U ATIMIQ CIKIAI nDACTQ%QnADn Akin t'nWAMITTCC ADDI If'ATInAI DCI_ CIAIAI A-
QwgjnVG Vr II1IVVIvir- %-j 1^1 GIvIGIr 1
Section 2-11.1(1) 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 First Name Middle Name/Initial
2021 Burstein Harvey Jay
Mailing Address — Street Number, Street Name, or P.O. Box
1775 Washington Ave. PH 2
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 here. ❑
Filing as an Employee (chock one)
County ❑ Public Health Trust Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began ontended on
Filling as a Board Member (check one)
❑ County ❑ Municipal: Miami Beach
(Municipality)
Board where serving
Alternate address (if home address is exempt) I Work telephone
Tenn 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
Harvey Burstein Trust
1775 Washington Ave PH 2
Miami Beachm FL 33139
Trust income
Rental
3600 N. Lake Shore Dr. # 926
Chicago, IL
Rental income
Social Security
Washington DC
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
Date signed
RECEIVED BY ELECTIONS DEPARTMENT
❑ Hardcopy RECEIVED
❑ Electronic Copy
JAN 10 2023
CITY OF MIAMI BEACH
OFFICE 0v- ` F CITY CLERK
MIAMI .,. / . LI1 YwIUL (�.W] bUAKU & L,)MMII IttJ
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 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 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: 1 acknowledge that should my access card be lost, stolen or
damage, 1 will be responsible to pay a $10.00 replacement fee.
Rnnrel M.Pmhew Infnrmntinn
Date of Application:Jan 10, 2023
Applicant Name: Harvey J. Burstein
Board/Committee Name: Transportation
Address: 1775 Washington Ave. PH 2
E -Mail Address: Harvey. BursteinC)gmil.com
Work Phone:
Home Phone
Cell Phone: 786-301-9667
Preferred Contact Method:
Vphirlp Infnrmntinn
Tag:
xsobex
Color:
White
State:
Florida
Year:
2021
Make:
Lexus
Model:
ES300h
Applicant signature: AK
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2nd floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfi.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION — APPLICANT NAME
IPnrkinn nipnnrtmsant SP_rtinn
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature: A5
Signature: -5
Date Issued:
Date Completed: