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20.097 ApplicationsFrom:noreply@civicplus.com Subject:Online Form Submittal: Application for Appointment to Boards, Committees and Commissions Date:June 24, 2020 at 2:56 PM To :mayor@northamptonma.gov Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name DANIEL Last Name POLACHEK Title, if applicable Field not completed. Address1 P O BOX 234 335 SOUTH ST Address2 Field not completed. City NORTHAMPTON State MA Zip 01061 Home Phone 4135843365 Work Phone 4135845809 Cell Phone 4132225320 Occupation & Place of Employment DANIEL W POLACHEK PC CPA CFP Email DAN@DWPOLACHEK.COM Are you a Northampton resident? Yes Years Lived in Northampton 39 Age 60 - 69 Sex Male Racial / Ethnic Background CAUCASION Boards and Committees Registrars, Board of Political Party Afﬁliation Republican Please list "other" board or committee of interest Field not completed. What skills and experience will you bring to this com‐ mittee assignment? CURRRENT Are you currently serving or have you served on any city committee? Yes Please list other city com‐ mittees you have served on BOARD OF REGISTRARS Required: Please read the following, by signing below you state that you under‐ stand and agree. The ﬁling of this form does not guarantee my appointment. An application is kept on ﬁle for two (2) years; after that I must ﬁle a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Em‐ ployee under MGL Chapter 268A and thereby subject to Conﬂict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conﬂict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature DANEIL W POLACHEK Date 6/24/2020 Email not displaying correctly? View it in your browser. Mayor of Northampton Mass. <mayor@northamptonma.gov> Online Form Submittal: Application for Appointment to Boards, Committees and Commissions 1 message noreply@civicplus.com <noreply@civicplus.com>Tue, Jun 23, 2020 at 5:03 PM To: mayor@northamptonma.gov Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name Aelan Last Name Tierney Title, if applicable Field not completed. Address1 30 Francis St. Address2 Field not completed. City Northampton State MA Zip 01060 Home Phone 413-584-8706 Work Phone 413-259-1630 x111 Cell Phone 413-575-5220 Occupation & Place of Employment President, Architect, Kuhn riddle Architects Email atierney@kuhnriddle.com Are you a Northampton resident? Yes Years Lived in Northampton 25 Age 50 - 59 Sex Female Racial / Ethnic Background White/Irish Boards and Committees Central Business Architecture Committee Please list "other" board or committee of interest Field not completed. What skills and experience will you bring to this committee assignment? As a licensed architect, with more than 25 years of experience in new construction as well as historic renovations, I provide the board both an aesthetic and technical opinion on the projects presented to the board. Having served on the Central Business Architecture Committee for several terms, I am also very familiar with the guidelines, and as chair, I believe, I have provided solid leadership for the board. Are you currently serving or have you served on any city committee? Yes Please list other city committees you have served on I am currently chair of the Central Business Architecture Committee Required: Please read the following, by signing below you state that you understand and agree. The ﬁling of this form does not guarantee my appointment. An application is kept on ﬁle for two (2) years; after that I must ﬁle a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conﬂict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conﬂict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature Aelan B. Tierney Date 6/23/2020 Email not displaying correctly? View it in your browser. Mayor of Northampton Mass. <mayor@northamptonma.gov> Online Form Submittal: Application for Appointment to Boards, Committees and Commissions noreply@civicplus.com <noreply@civicplus.com>Thu, Jun 25, 2020 at 5:08 PM To: mayor@northamptonma.gov Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name Booker Last Name Bush Title, if applicable MD Address1 119 Pine Street Address2 Field not completed. City Florence State MA Zip 01062 Home Phone 413-727 8497 Work Phone Field not completed. Cell Phone 617-947-7882 Occupation & Place of Employment Physician, Baystate Medical Center Email bookertbush@msn.com Are you a Northampton resident? Yes Years Lived in Northampton 10 Age 60 - 69 Sex Male Racial / Ethnic Background Black Boards and Committees Human Rights Commission Please list "other" board or committee of interest Field not completed. What skills and experience will you bring to this committee assignment? I have been on the Human Rights Commission for 3 years, would like to continue. I am hoping to perhaps serve on the Police advisory committee as a rep from the Human rights commission Are you currently serving or have you served on any city committee? Yes Please list other city committees you have served on Human rights Commission Required: Please read the following, by signing below you state that you understand and agree. The ﬁling of this form does not guarantee my appointment. An application is kept on ﬁle for two (2) years; after that I must ﬁle a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conﬂict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conﬂict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature Booker Bush Date 6/25/2020 [Quoted text hidden] Mayor of Northampton Mass. <mayor@northamptonma.gov> Online Form Submittal: Application for Appointment to Boards, Committees and Commissions noreply@civicplus.com <noreply@civicplus.com>Wed, Jun 24, 2020 at 2:46 PM To: mayor@northamptonma.gov Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name Helen Last Name Kahn Title, if applicable Field not completed. Address1 188 Federal Street Address2 Field not completed. City Florence State MA Zip 01062 Home Phone Field not completed. Work Phone Field not completed. Cell Phone 413-237-9585 Occupation & Place of Employment Field not completed. Email helenjkahn@gmail.com Are you a Northampton resident? Yes Years Lived in Northampton 21 Age Field not completed. Sex Field not completed. Racial / Ethnic Background Field not completed. Boards and Committees License Commission Please list "other" board or committee of interest Field not completed. What skills and experience will you bring to this committee assignment? 2 years on License Committee Are you currently serving or have you served on any city committee? Yes Please list other city committees you have served on License Committee Required: Please read the following, by signing below you state that you understand and agree. The ﬁling of this form does not guarantee my appointment. An application is kept on ﬁle for two (2) years; after that I must ﬁle a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conﬂict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conﬂict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature Helen J Kahn Date 6/24/2020 Email not displaying correctly? View it in your browser. Mayor of Northampton Mass. <mayor@northamptonma.gov> Online Form Submittal: Application for Appointment to Boards, Committees and Commissions noreply@civicplus.com <noreply@civicplus.com>Wed, Jun 24, 2020 at 12:01 PM To: mayor@northamptonma.gov Application for Appointment to Boards, Committees and Commissions City of Northampton Application for Appointment to Boards, Committees, and Commissions Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060 First Name James Last Name Ryan Title, if applicable Park and Recreation Address1 56 Leonard St Address2 Field not completed. City Leeds State Ma Zip 01053 Home Phone 413-587-8285 Work Phone Field not completed. Cell Phone 413-348-2931 Occupation & Place of Employment Verizon Email Theryans5@verizon.net Are you a Northampton resident? Yes Years Lived in Northampton 58 Age 50 - 59 Sex Male Racial / Ethnic Background Field not completed. Boards and Committees Parks and Recreation Commission Please list "other" board or committee of interest Field not completed. What skills and experience will you bring to this committee assignment? All ready on the committee. Are you currently serving or have you served on any city committee? Yes Please list other city committees you have served on Field not completed. Required: Please read the following, by signing below you state that you understand and agree. The ﬁling of this form does not guarantee my appointment. An application is kept on ﬁle for two (2) years; after that I must ﬁle a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conﬂict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conﬂict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form. Signature James M. Ryan Date 6/24/2020 [Quoted text hidden]