Baruch JacobsMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
RECEIVED
JUL 25 2024
CITY OF MIAMIoFcriii±;3%\CH•CLERK
OFFICE OF THE CITY CLERK
Email:BC@miamibeachf].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):
[/E1am a resident of the City of Miami Beach for six months or longer.
Home Address.5025 Collins Ave Miami Beach,FL 33140
l 1have 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:Miami Beach Cosmetic and Plastic Surgery Center
Business Address·400 Arthur Godfrey Rd Suite 305 Miami Beach,FL 33140
D 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:-------------------------
Hg[mess Jr]fess,-
"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)9/it are tru
07/24/2024
Sigt
Baruch Jacobs,MD
Date
Printed Name