Roman Jones - Mokai Loungem MIAMIBEACH v~~g~
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the
passage, defeat or modification of any ordinance, resolution, action or decision of any commissioner; any action,
decision, recommendation of the City Manager or any city board or committee; or any action, decision or
recommendation of any city personnel during the time period of the entire decision-making process on such action,
decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city bond or
committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The
teen "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Jones Roman
NAME OF LOBBYIST: (Last) (First) (M.I.)
Mokai Lounge, LLC 690 Lincoln Road, Suite 201 Miami Beach, Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 695-8411 (786) 507-3449 roman theopium roup.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
Mokai Lounge, LLC
NAME OF PRINCIPAL/CLIENT:
Mokai Lounge 690 Lincoln Road, Suite 201 Miami Beach, Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
___ _ (305) 695-8411 (786) 507-3449 hassan _theopium roup.com
TELEPHONE NUMBER: FAX NUMBER: (Optional) .EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Roman Jones, as Manager of
Mokai Lounge, LLC
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE
OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
See attached Disclosures of Interest.
11. SPECIFIC LOBBY ISSUE:
Modification to a Modified Conditional Use Permit for an existing Neighborhood Impact Establishment to allow an
outdoor cafe without entertainment and without dancing in the adjacent existing surface parking lot under File No.
1764 for the property located at 219 23rd Street - 235 23rd Street (a/k/a 233 23rd Street).
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2-482(g) include a
statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of IndividuallTitle
City of Miami Beach Planning Board B An
N
n Financial Fa 'I'a or Professional Relationshi
- ~-
City of Miami Beach Planning Staff o
e
None - - ~ , . ,_, _„ ) ~ ~ ~ ~
City of Miami Beach Mayor/Commissioners
Ci
f Mi
i B None ~~ :f1 ~~ ~~ ~(~(~ o~QZ
ty o
am
each Committees None
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FLAT RATE OR OTHER):
LOBBYIST DISCLOSURE: (Required) $0.00, no additional compensation for lobbying.
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). $0.00, no additional compensation for lobbying.
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^Yes ®No: Are you lobbvina on a present or pendina bid for aoods. equipment or services or on a
present or pendina award for aoods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^Yes ®No• Are you lobbvina on a pendina application for a Development Agreement with the City or
application for chance of zoning map designation or chance to the Citv's Future Land Use Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees..
^Yes ®No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WE AS COMPENSATION
RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YE A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION U ING THE REPORTING
PERIOD.
Signature of Lobbyist -
I do solemnly swear that all of the foregoing
provisions contained in Section 2-482 of theme
Signature of Lobbyist:
Signature of Principal/Client:
true and correct and at I have rea or am familiar with the
:h.Gity Code and all rep ing requir ents.
ones, as Ma ger of Mokai Lounge, LLC
VI. LOBBYIST IDENTIFICATION: PRINC PAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
~ Personally known (Lobbyist) ~(. Personally known (Principal)
,,'~~"" Vale
VII. SIGNATURE AND STAMP T/I,~ ~•'i-RY °o~,,, TPS Simoens
,.:1~, ~:t Simoens _: ~'......:~ s_CAMMiSSioN ~DD809582
°' • `~~=COMMISSION+e!DD809 ~ ~'Qc
State of Florida, County of Miami-Ds~fe `_ mate of Florida, County of Miami-Dacf~~:•••••~-~, ~P+RES:JULY29, 2012
Sworn to and subscribed before me- s •••••~= ~°+Res: JULY 29, 20$'~vorn to and subscribed before me . ~'''~ ~~~''~ WWW.ApRONNOTARY.carn
of ~ ,.•
This'Z~ day of~, 2010 ~'"~^~"' www•AnRONNorpRrc~lnis2~day of.~_, 2010
Sig li - St f Florida Sig ure u No tate Florida
Nota ' ation of Lob it's signature No ~ ion o nature
TO BE COMPLETED~Y CITY CLERK'S
egistration fee:'[] Yes [ ] No Amount Paic
Registration Form received and verified by:
.OBBYIST\Lobbyist Registration Form 32708.d
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK office CityClerkCa>miamibeachfl.pov
Tel: 305.673.7411, Fax: 305.673.7254
LOBBYIST NAME:
Roman Jones
I understand that no later than October 18~ of each vear, I must file the following forms, pursuant to Section 2-485 of
the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timety basis will result in my name being transmitted to the Miami-Dade County
Commission on Ethics and for code violation evaluation.
In addition, once an i sue I have registered to lobby on has been resolved, I am required to immediately notify the
City Clerk's Office for ~bbyist withdrawal in writing.
/''L~~1~
Date:
NAME AND ADDRESS
MOKAILOUNGE.LLC
Mokai lounge Manager, LLC
690 Lincoln Road, Suite
Miami Beach, Florida 33139
MOKAI LOUNGE MANAGER. LLC
Roman Jones Companies, Inc.
3165 Pine Tree Drive
Miami Beach, Florida 33139
Mokai Investors, LLC
7901 SW 6th Ct.
Plantation, Florida 33324
Mokai 23, LLC
1137 Biscayne Point Road
Miami Beach, Florida 33141
Nomade Investments, Inc.
230 N.E. 107th Street
Miami Shores, Florida 33161
JL Club Holdings, LLC
14500 Ocean Bluff Drive
Fort Meyers, Florida 33908
Haute Investments, Inc.
P.O. Box 190754
Miami Beach, Florida 33119
ROMAN JONES COMPANIES. INC.
Roman Jones
3165 Pine Tree Drive
Miami Beach, Florida 33139
MOKAI INVESTORS. LLC
Mitchell Rubinson
7901 SW 6th Ct.
Plantation, Florida 33324
ANV Investment Group, LLC
3801 Collins Avenue, Apt. 1404
Miami Beach, Florida 33140
EXHIBIT "B"
DISCLOSURE OF INTEREST
Page 1 of 2
OFINTEREST
100
55.118
11.811
11.811
5.906
11.811
3.543
100
50
50
NAME AND ADDRESS % OF INTEREST
MOKAI 23, LLC
Francis Milon 66.5
1137 Biscayne Point Road
Miami Beach, Florida 33141
Eric Milon 33.5
1137 Biscayne Point Road
Miami Beach, Florida 33141
NOMADE INVESTMENTS, INC.
Hassan Benjelloun 100
230 N.E. 107th Street
Miami Shores, Florida 33161
HAUTE INVESTMENTS. INC.
Jaime Rubinson 100
P.O. Box 190754
Miami Beach, Florida 33139
JL CLUB HOLDINGS. LLC
Justin Levine 100
14500 Ocean Bluff Drive
Fort Meyers, Florida 33908
ANV INVESTMENT GROUP.-LLC
Dev D Dabas
3801 Collins Avenue, Apf.1404 50
Miami Beach, Florida 33140
Sumedha Dabas
3801 Collins Avenue, Apt. 1404 50
Miami Beach, Florida 33140
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