Gabriella KalmanowiczMA/AM!BEACH
RECEIVED
MAR 72023
City of Miami Beach
d0 Convention Center Duve
Mos Dach. Florido 33139
OFFICE OF THE CITY CLERK
Email BC@mi@mueactf.gov
Telephone 305 673 7411
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADOE
I am in complianco with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
lam a resident of the City of Miami Beach for six months or longer.
Home Addros330 w 471h St Miami Beach, FL
p !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 Busine The Surgeon's Daughter
Businoss Address 400 Arthur Godfrey Rd. Miami Beach FL, 33140
a lam a full-time em ployee of a business (for a minimum of six months) an d l am based in an office or
other location of the business that is physically located in Miami Beach (for a minimu m of six months)
[pqmno to{ y1pf9{S
Py1fS, J(][foes-
Ownership Interest" means the own ership of ten percent (10%) or more (including the ownership ol
10% or more of the outstanding capital stock) in a business
"Business" m eans any sole prop rietorship, sponsorship, co rporation, limited liability company, or other
entity or business association
Under penalties of perjy try, I declare that I have read the foregoing document and that the facts stated in it
a"%/. lo<d 0so6r2o02s ------------- Signature Date
Gabriella Kalmanowicz
Printed Name
NOTARY
Sworn to (or affirm ed) and subscribed before me, by means of s/physical presence or r online notarization, - this (9 day or T\a o _,2o1Sy [al@ttf_ ct_n or_2
(City of Miami Beach Board/Commit tee Member)
/ Produced ID pQiyC'Lie €
Form of Iden tificat ion
Personally Known
.- %
Notary Publlc State ol Florida
Yadoen Beltre Zayas "%.e:
Exp 10/25/2025
3.g un«wooeegoop«need
(NOTARY SEAL)
Sig
Na d