Michael W. Larkin - Chalk's on the Beach MIAMI BEACH
W 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 board or committee. The
term specifically includes the principal as well as any employee engaged in lobbying activities. The term"Lobbyists"has specific exclusions.
Please refer to Ordinance 2004-3435.
Larkin Michael W.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell&Fernandez, PA 200 S. Biscayne Blvd,Suite 850 Miami Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)377-6231 (305)377-6222 mlarkmi-iftrzonincilaw.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or a-mail address.
I. LOBBYIST RETAINED BY:
Chalk's on the Beach, LLC—Joseph Blount, Manager
NAME OF PRINCIPAL/CLIENT:
Chalk's on the Beach. LLC 605 Lincoln Road, Suite 200 Miami Beach Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)674-1712 (305)673-4879 jblount55 @gmail.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:Joseph Blount, Manager
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION PARTNERSHIP OR TRUST: See attached exhibit
II. SPECIFIC LOBBY ISSUE:
Development approvals and permitting issues for property located at 1234 Washington Avenue, Miami Beach, FL
Issue to be lobbied(Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4)include the commissioner of personnel sought to be lobbied,and whether the lobbyist
has entered into contractual relationship(paid or unpaid)with said city commissioner or personnel from 12 months preceding
such person's commencement of service with the city to the present date,stating the general nature of the subject contractual
relationship.
Sec 2482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Planning Department and Building Department None X
Staff
PB, HPB, BOA,City Commission,as necessary* None X
Q/� Ql� 1 r-Gp/'CS�01 G
Pursuant to City Code Sect on 2-482(g)Every registrant shall be require to state the extent of any business,financial,familial or
professional relationship,or other relationship giving rise to an appearance of an impropriety,with any clurrel�Eity comn*sioggt.
or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482 Any Financial Familial or Professional Relationship 831 ZEOZ
None.
*Unless an issue is legislative in nature,PB,HPB,BOA,&City Commission members are not lobbied outside of a public hearing setting. c :r J
�3
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLATRATEOR
OTHERt
A) LOBBYIST DISCLOSURE: (Required) $445.00
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $445.00
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 X Now Are you lobbying on a w went or egg bid for goods,eq pment or services,or on a present or
pending award for goods,eauinment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
Yes X No• Are you lobbyjng on a ep nding application for a Development Agreement with the City or application
for change of zoning man designation or change to the City'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 a not-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 X Nom Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT
UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF
MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN
NO EXPENDITURES OR COMPENSATION DURING THE REPORTING�- C
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach Ci Code and all re rting requirements.
Signature of Lobbyist: (,Z
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICAT N- PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Jy., Form of Identification
Personally known (Lobbyist) o _ Personally known (Principal) KAREN LEWIS
MY COMMISSION#EE014741
VII. SIGNATURE AND STAMP OF NOTA EXPIRES August 05,2014
398-0153 FioridallotaryServicexom
State of Florida, County of Miami-Dade a m Cn State of Florida,County of Miami-
Sworn to and subscribed before me 0 Z Swor aDd subscri before me
This i S T day of 20L�, Z° This day o ,
Q��
Signature of Public Nota —S e of rida E Signature If Public Notary—State of Florida
Notarization of Lobbyist's signature Notariz ion of Principal's signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes[ ] No Amount Paid MCR# Date Paid
Lobbyist Registration Form received and verified by: <5�f Entered By:
Revised 1/11/2011
I
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City of Miami Beach, 1700 Convention Center Drive,Miami beach, Florida 33139,www.miamibeachfi.gov
CITY CLERK Office CityClerkCmiamibeachf1.gov
Tel:305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME:
I understand that no later than February 28th of each year, I must file the following form, 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 and Compensation Form
Failure to file these forms on a timely 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 issue I have . registered to lobby on has been resolved, I am required to
immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
9 A, a�
Signature: Date:
EXHIBIT
DISCLOSURE OF INTEREST
Chalk's on the Beach,LLC,a Florida Limited Liability Company
605 Lincoln Road,Suite 200
Miami Beach,Florida 33139
NAME OF INTEREST HOLDER % INTEREST
1. Joseph W.Blount Revocable Trust 75.0%
Joseph W. Blount,Trustee
2535 Lake Avenue
Miami Beach, Florida 33140
Joseph W. Blount, Beneficiary 100%
2535 Lake Avenue
Miami Beach, Florida 33140
2. Robert Chalk 10.0%
3451 NE 1"Avenue
Apartment M704
Miami, Florida 33137
3. Sayra Moto 15.0%
1368 Normandy Drive
Miami Beach, Florida 33141
TOTAL for Chalk's on the Beach,LLC 100%