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Tomas Salerno 12.31.26Ml/A\Ml BOARD AND COMMITTEE CHECKLIST APPOINTEE: Tomas Antonio Salerno DATE OF APPOINTMENT. Feb 7, 2023 Scan o Scan o Scan o BOARD/COMMITTEE. llealth Facilities Authority Bo@BS Appointed by Commissioner Ricky Arriola FOR SCANNER FOR CLERK STAFF E)]39 Scan o o Letter of Appointment TERMEND: pv[3]/2¢ TERM LIMrr. I~l 'O Scan o o Letter of Reappointment o SOP', 9'. Letter of Appointment/Reappointment e-mailed to Committee Liaison on 2'ap3 [·[ o Board and Committee Application (Completed om IO IL}'Q2, o Resume/curriculum Vitae J4.3 o Diversity Statistics Reporting (Completed on Y]l. o Oath RECEIVED FEB 7 2023 CITY OF IAMI BEACH OFFICE r AF CITY CLERK IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK City Code Ordinance Section applicable to the agency, board or committee t City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 t 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 / 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 o Source of Income Statement o Acknowledgment of Financial Disclosure Requirement O Board and Committees Liaison Responsibilities O DIVERSITY STATISTICS REPORTING Keep COL±u! Received o#. February 7, 2023 Signed by ho " l Scan o Scan o Date Processed on: February 7, 2023 Date Scanned on: Board or Committee Member By Employee: ---,----,--,-\lJVl-..,-,,,.,...+-::---:-:-:--:-:-,-----~---- City Cler~e Staff Initials GU@Y'0" syEmo»veer Date City Clerk's Office Staff Initials CONCLUDED & RESIGNATION LETTIERS ._.,.____... 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:ICLER\BOARD AND COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx Ve ore commied to pwovdig excellent puii: service and salaty to all who live work, and pkwy in our vibyoni, lropical, historic community M IAM I BEACH City of Miami Beach, I/OO Convention Canter Drive, Miami Boach, Florida 33 139 yaw_miaIibggchllgoy OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk Tel: 305.673.7411 , Fax. 305.673.7254 Email: City Clerk@miamibeach!l.gov February 07, 2023 Mr. Tomas Salerno 25 South Hibiscus Drive MIAMI BEACH, FLOR IDA 33139 RE: Health Facilities Authority Board Dear Mr. Tomas Salerno: Congratulations! You have been appointed by the City Commission to the agency, board or committee named above for a term ending: 12/31/2026. 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. Regards, cc: Monica Beltran, Parking Director Allison Williams, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements City Code/Or dinan ce section applicable to agen cy, board or comm ittee City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 Ordinance No. 2006-3543 - Am endm en t 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 MIA,M/BE City of Miami Beach, OO Convention Canter DOivo, Miami Beach, Florida 33 139 wy.riamubaachll.go OFFICE OF THE CITY CLERK, Rafol E. Granado, Cy Clerk Tel: 305.673.7411, Fox. 305.673.7254 Email: Cit/lark @miamiboochfl.gov Oath of Office Oath of Civility and Acknowledgements TO: Mr. Tomas Salerno RE: Health Facilities Authority Board 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. 12/31/2026. 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. ~--2>·_·_ .. ..- Mr. Tomas Sale~ Sworn to and subscribed before me this __3:~, 2023 Keila Mena Caceres 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. City of Miam i Beach 1700 Convention Center Drive Miami Beach, Florida 33 139 OFFICE OF THE CITY Cl.ERK Email: BC@miamibeachfl.gov Telephone: 305.673.7411 RECEIVED FEB 72023 CITY OF MIAMI BEACH OFFICE OF THE CITY CLER A F F ID A V IT O F A F F IL IA T IO N W IT H T H E CITY OF MIAMI BEACH STATE OF FLORIDA C O UN T Y OF MI AM I-DAD E I am in com pliance with the affiliation requirement of Miam i Beach City Code Section s 2-22 (4 ), as (check (✓)all that apply): l2J I am a resident of the City of Miami Beach for six months or longer. Home Address5 S o ut h H ibi scu s D ri v e , Miami Beach, FI 33139 □I have an ownership intere st (for a minim um of six months) in a business established in the City of Miam i Beach (fo r a minimum of six months). []Qr ()f {[[f@}oooooo P1]/P o , JS]r}....or---or«or·- I am a full-tim e em ployee of a business (for a minim um of six months) and I am based in an office or other location of the business that is physically located in Miam i Beach (fo r a minimum of six month s). [/Qr/r9 ()[ [4/n@Sb}coon«oooooooooooooo- 4[p, J}(}f9}_.ooooooooooo- "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 docum ent and that the facts stated in it are true. 2Za4 February 7. 2023 Signature Date Tomas Antonio Salerno Printed Name NOTARY Sworn to ( or amrJ.· da. nd su.bs·c·····ribed before. ··m·e·-' by mean.· S 0\□.. p··.·.h .. y·. sica .. l···p···r· .e. s.e:ce or O online notarization, vs 7lay a i.«lug] 033 »_U ea.aodko»au, D (City of Miami Beach Board/Committee Member). Produced ID fD Le #tS46s-go1-44-0ll_o Form of Identification tt-..at.tit.tt-at - Name of Notary, Typed, Printed, or Stamped , {JNAGOL£2 ota9#Eke{ill Commission # HH 192395 My Comm. Expires @ct 31, 2025 Bonded through National Notary Assn, pogo«ggp /"/0 1IAMIBEA CH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florid 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK Email: BC@miamibeachfl.gov Telephone: 305.673.7 411 DIVERSITY STATISTICS REPORT Salerno Tomas A 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: LZJ Male [ Female LJ oner Ll t prefer not to answer. Race/Ethnic Categories: What is your race? D African American/Black DI Asian or Pacific Islander LO Caucasian/wh ite D Native American/American Indian D Other - Print Race: or □I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? Glves (Jo D I prefer not to answer. Do you consider yourself Physically Disabled? es z0o D I prefer not to answer this question. Page 6 of 6 F:CLER\$ALL\REG\BOARD AND COMMIT TEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.d0cx Updated: June 2020 City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl,gov OF FICE OF THE CITY CLERK Email: BC@miamibeachfl.gov Telephone: 305.673 7411 BOARD & COMM ITTEE 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) Salerno Tomas Last Name First Name A Mwaate 1tar I understand that no later than July 1,of each year all memb ers of Boards and Com mittees of the City of Miami B e ach, in clu d ing th o se o f a purely advisory nature, are required to comply with Miami-Dade County Financial D iscl o sure R e q u irem e n ts. O ne of th e fol lowi ng form s m ust be filed with the City Clerk of Miami Beach , 1700 Con vention 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 o f n o m o re tha n $5 0 0 , 60 da y s in jail, or both. ...=- 2a Date I 1 M e mbers of the Planning Board and Board of Adjustment will be notified directly by the State of Florida, p urs ua nt to F.S . $112 .3 14 5 (1 )a ), to file a S tatem en t of Fi n a n ci al In tere sts (Form 1) wi th th e Mi am i -D ade Co un t y S u pe rv iso r of E le ctio n s by 12 :0 0 n o o n , Ju ly 1. P la n n ing B o a rd an d B o a rd o f A d justm e n t m e m b e rs w ho file the ir F orm 1 with the C o u nty S u p e rv iso r o f E le ctio ns auto m atica lly satisfy the C o unty's fin a n cial d isclo sure re qu ire m e nt a s a M iam i B e ach C ity B o a rd/C o m m itt ee m e m b e r and n e ed no t file a n ad d itio n al fo rm w ith the O ffi ce o f th e Ci ty Cl er k . H o w ever , com p lian c e wi th th e C o un t y discl o sure req ui rem en t do e s no t sati sfy the S tate req uirem e nt. Page 5 of 6 F:ACLERISALLIRE G\BOARD AND COMMITTEE APPLICATIONS FINAL. DORAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.doc Updated: June 2020 MIAMl·DADE. EIII 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 2022 Salerno First Name Tomas Middle Name/Initial A Mailing Address - Street Number, Street Name, or P.O. Box 25 South Hibiscus Drive City, State, Zip Miami Beach, Florida, 33139 lf your home address is your malling 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. D Filing as an Employee (check one) [] county □Public Health Trust [] Municipal: (Municipality) Department he Position or Title Employee ID Number Work address I Work telephone Employm ent began on/ended on Filing as a Board Wember (check one) [] county [.] Municipal: _Ma%a" (Municipality) Board where serving Health Facilities Authority Board Alternate address (if home address is exempt) ! Work telephone (305) 585-5271 ! Term began on/ended on 2023-2026 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 University of Miami Miller School 1611 NW 12th Avenue, Miami, Clinical Practice in Cardiac of Medicine Florida, 33136 Surgery no i,+a I hern·t.Jy ..•. swe. ar. (or···aff.irm) tha·t·t.he i.n· f.orma .. ·ut.ioonn. a abo.oovv~e I i:.:s a~tr(Jf;.···.·. nd correct statement. - S~@nature ot Person Disclosing KL, +/o a3 1 Date signed RECEIVED BY ELECTIONS DEPARTMENT: tar«too»RECE IVED O Electronic Copy FEB 7 2023 CITY OF MIAMI BEACH EE: OFFICE USE ONLY Accepted: Y I N Deficiency. Processed Date/initials: 138_SP-14 CO 2016 Scanned Date/Initials....-...... Ml City of Miami Beach, PARKING DEPARTMENT 1755 Meridian Avenue, Suite 200/Miami eoch, FL 33139/Ph: (305) 6737505 0r (305) 673.7000 ex4. 6200 CITYWIDE (CW) BOARD & COMMITTEES PARKING APPLICATION 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 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. Board /ember Information Date of Application: February 7, 2023 Applicant Name: Tomas Antonio Salerno Board/Committee Name: Health Facilities Authority Board Address: 25 South Hibiscus Drive, Miami Beach, Florida, 33139 E.-Moil Address' tsalerno@med.miami.edu Work Phone: 3055855271 Home Phone 3056726027 Cell Phone: 3056324042 Preferred Contact Method: 3056324042 Vehicle Information Tog: /LCLM57 Color: grey State: Florida Year: 2018 Make: Tesla Model: 3 2 T_ 3/102-3 Applicant Si+nature: '( 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 em ail to: ParkingRec}ption@miamibeachfl.gov e-mail subject: BOARD & COMMITTEE PA!!KING APPLICATION -- APPLICANT NAME Parking Department Section PERMIT SYSTEM GARAGE ACCESS Expiration Date: ID Card Serial #: Issued By Print Name: Print Name: Signature: es Signature: e5 Dale lssued: Date Completed.