Michael Goldberg 09.01.24RECEIVED
MIAMI BEACH JUN 3 2024
CITY OF MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST " or"
APPOINTEE: Michael S. Goldberg DATE OF APPOINTMENT: May 15, 2024
BOARD/COMMITTEE: Historic Preservation Ad Hoc Cc Appointed by: City of Miami Beach Commissi
FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment TERM END: TERM LIMIT: _
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on _
o Board and Committee Application (Completed on _,
o R~sum~/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _,
o Oath
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
✓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 Statement
o Board and Committees Liaison Responsibilities
o Diversity Statistics Reporting
[Z] I acknowledge that pursuant to Sec. 2-22(9) of the Miami Beach Code of Ordinances, I will be removed
from my board/committee upon failure to attend 33% of the regularly scheduled meetings.
Sec. 2-22(9) If any member of an agency, board or committee fails to attend 33 percent of the regularly scheduled
meetings per calendar year, such member shall be automatically removed. To calculate the number of absences
under the 33 percent formula, .4 or less rounds down to the next whole number and .5 or more rounds up to the
next whole number.
NOTE: Members of the Land Use Boards will be removed upon failure to attend three of the regularly scheduled
meetings per calendar year; or upon abstaining from voting due to a conflict of interest on four different
applications within a calendar year. A member who is removed shall not be reappointed to membership on the
board for at least one year from the date of removal.
Received on: _M_ay_3_0_, 2_0_24 Signed by X __ 7nc-1( __ Cf¼__;___1//___::0--::;...._--,4-t;/O_LD __ a_~=----,4----
Date Board or committee fnBer
Processed on: __ \e.....__· 3_._rc_Y_. -- By Employee: _...._A; __ ._l_._. _
Date" City Clerk's Office Staff Initials
WVe are committed to providing excellent public service and salely to all who live, work, and play in our vibrant, tropical, historic community.
09.01.24 09.01.24
05.17.2411.20.2023
5.30.24
MIAMI BEACH
City of Miami Beach, I/O0 Convention Conler Drivo, Miami Boach, Florida 33 139 yyaw.miamibeachll.gov
OFFICE OF THE CITY CLERK, Rafaol E. Granado, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: Ci/Clerk @miamiboochfl.gov
May 15, 2024
Mr. Michael Goldberg
11480 North Bayshore Drive
North Miami, FL 33181
RE: Ad Hoc Historic Preservation Ordinance Review Advisory Committee
Dear Mr. Michael Goldberg:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 09/01/2024.
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.
"7s
Rafi Granado
City Clerk
cc: Monica Beltran, Parking Director
Deborah Tackett, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
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
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MI
City of Miami Beach, 1ZOO Cononlion Conlan Diva, Miami Boch, Florida 33 139 yaw_IiaIIiLcgachf]_gov
OFFICE OF THE CITY CLERK, Rofaol E. Granado, City Clerk
Tel: 305.673.7411, Fox 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Michael Goldberg
RE: Ad Hoc Historic Preservation Ordinance Review Advisory 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: 09/01/2024.
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.
tcre gee
Mr. Michael Goldberg
Sworn to and subscribed before me this ?}, y day or May _,2024
*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.
MIAMI BEACH
RECEIVED
JUN 3 2024
CITY OF MIAMI BEACH
OFFI • AECITY CLERK
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check ( ✓) all that apply):
D I am a resident of the City of Miami Beach for six months or longer.
[ {9fe ]]feS,
D 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).
[[gr9 (f Hy[[%SS,
[[JS[[]es,S J((fosS,
] 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: First Horizon Bank
Business Address: 400 W 41 st Street Suite 102
"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. 327me May 30, 2024
Date
Michael S. Goldberg
Printed Name
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach!l.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
DIVERSITY STATISTICS REPORI
Dihel _5
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:
L Mlle
[lremale
0 Other
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
DI African American/Black
D Asian or Pacific Islander
EJCaucasian/white
0 Native American/American Indian
D Other - Print Race: ------------- □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Tves
(No
D I prefer not to answer.
Do you consider yourself Physically Disabled?
ves No
D I prefer not to answer this
uestion.
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.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
Goldberg
BOARD & COMMITTEE ACKNOWLEDGEMENT STATEMENTS
Michael s
Last Name First Name Middle Initial
Acknowledgment of fines/suspension for Board/Committee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
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 Copy of your latest Federal Income Tax Return.
Members of the Planning Board and the Board of Adjustment must electronically file a "Statement of Financial
Interests (Form 1)" directly with the Florida Commission on Ethics.
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.
Acknowledgment to Comply with Miami Beach Code of Ordinances Division 1 Sec. 2-22 (23)
I understand that commencing with terms beginning on or after January 1, 2024, and as a condition of applying
for appointment to a City agency, board, or committee, I voluntarily agree that in the event I file with the City
Clerk a Statement of Candidate formally announcing candidacy for City elective office, such filing with the City
Clerk shall be deemed a tender of resignation from the City agency, board, or committee
May 30, 2024
Signature Date
1 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 electronically file a Statement of Financial Interests (Form 1) with the Florida
Commission on Ethics by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the Florida Commission on Ethics 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.
Page 6 of6
F:\CLER\$ALLIBOARD AND COMMITTEES DATABASE\Board and Committee Application\BOARD AND COMMITTEE APPLICATION FEB 2024.docx
Updated: February 22, 2024
MIAMl·DADE- EI SOURCE OF INCOME STATEMENT
Section 2-11.1(@) 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
2023 Goldberg Michael s
Mailing Address - Street Number, Street Name, or P.O. Box
11480 North Bayshore Drive
City, State, Zip North Miami, Florida 33181
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.[l
Filing as an Employee (check one}
[] county □Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one}
[] county [] Municipal: City of Miami
- t (Municipality)
Board where serving 1
Miami Beach
Alternate address (if home address is exempt) I Work telephone I Term began on/ended on
305-468-4148 5/17/2024
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
400 W 41st Street Suite 102 Banking First Horizon Bank Miami Beach, Florida
221An
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
May 30, 2024 _
Date signed
RECEIVED BY ELECT1ii! DEP □Hardcopy
LI Electronic cdb// 3 2024
A"VA MIAMI BEACH t.rr ors yr CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/Initials: _
138 SP-14 COE 2016
MIAMI BEACH BOARD & COMMITTEES Lal PARKING APPLICATION City of Miami Beach, PARKING DEPARTMENT
1755 Meridian Avenue, Suite 200 Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200 PARKING
As a Board/Committee member you are entitled to a Citywide Parking Permit, which includes City Hall
garage (G7) parking access (Access Card), or a complimentary Citi Bike/Deco Bike Membership, or a
discounted MDC Monthly Transit Pass throughout your term.
Board Member Information
Date of Application: May 30, 2024 I already have citywide parking through the BO/
Applicant Name: Michael Goldberg
Board/Committee Name: Historic Preservation Ad Hoc Committee
Address: 11480 North Bayshore Drive North Miami, Fl 33181
E-Mail Address: muchael.goldbergenrsthorizon.com
Work Phone: 305-468-4168 Home Phone: 305-891-4539
Cell Phone: 305-213-3763 Preferred Contact Method: Cell
Please Choose One (1) Option:
'} citywide Parking Permit/G7 Access card [} CW Bike/peco Bike Membership [ ) Monthly Transit Poss
Vehicle Information (For Citywide Parking Permit/ Access Card Only)
Tag: D9BYZ Color: Black
State: Florida Year: 2016
Make: Lexus Model: 460GX
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". 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.
Applicant Signature: es 7CRA7 q0Lag
Please provide signed form to the Parking Department loc~ted at 1755 Meridian Avenue, 2nd 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
f:\ping\$man\rar\forms\cw boards&committees parkingform.doc form updated 1/18/2024