Omar JimenezMIAMI BEACH
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
RECEIVED
NOV 12 2024
CITY OF MIAMI BEACH
OFFICE OF HE CITY CLERK
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):
I✓I I am a resident of the City of Miami Beach for six months or longer.
Home Address:7324 GARY AVENUE,MIAMI BEACH,FL 33141
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).
[]are (f [3yg[/eSS,
[[Jg[[es,S (](]resS,
]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:BELLA CUBA RESTAURANT
Business Address:1659 WASHINGTON AVENUE,MIAMI BEACH,FL 33139
"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 ofJrjury,I declare that I have read the foregoing document and that the facts
stated in/lOir:,..t!V•-~
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Signature Date
OMAR JIMENEZ
Printed Name