Michael Larkin - 1906 Collins, LLC MIAMIBEACH
19
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 mlarkin @brzoninglaw.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
I. LOBBYIST RETAINED BY:
1906 Collins, LLC—Mathieu Massa, Manager
NAME OF PRINCIPAL/CLIENT:
1906 Collins,LLC 999 Brickell Avenue,Suite 600 Miami _ __ _Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)965-7882 (305)396-2857 mmassa @massainvestment.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: Mathieu Massa,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 1908 Collins Avenue
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
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any bpsiness,,fi j�nciai,.-fami'i0,or
professional relationship,or other relationship giving rise to an appearance of an impropriety,with any-current city comrrAsgilDner
or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed. 7
g M Wrl 23J Z10
Sec 2-482 Any Financial,Familial or Professional Relationship
None. yS
*Unless an issue is legislative in nature,PB,HPB,BOA,&City Commission members are not lobbied outside of a public hearing setting.
I
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
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 No: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or
pending award for goods, equipment 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 lobbying on a pending application for a Development Agreement with the City or application
for change of zoning map 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 No: 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 PERIOD.
Signature of Lob yist
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 City Code and all re rting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
�
Produced ID_ Produced ID D�1 z-� 22t�(p
�-0
Form of Identification Form of Identification
Personally known (Lobbyist) .1',"yf: Personally known (Principal)
3.
VII. SIGNATURE AND STAMP OF N rJ
m ,oi�a'°�e�•., KETTY MORA
State of Florida, County of Miami-Dade m State of Florida, County tf a ade°mary Public -State of Florida
Sworn to and subscribed before me ;1:2 81 Sworn and subscri d omm Expires Jun 28.2015
This 1 dd of FtB2llP\��( z'T' P EE 107587
��_ y , 20 This day of (�?
- �wzv
Signature of Public Notary tat f FI N Signature of 961ic Notary—'St of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
R CLERK'S USE ON�Y
Annual Registration fee: [ J Yes[ ] No Amount Paid _MCR# /'1 7 7 Date Pai
Lobbyist Registration Form received and verified by: Entered By:
Revised 1/11/2011
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33 139,www.miamibeochfLgov
CITY CLERK Office CityClerkCmiamibeachfl.gov
Tel:305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME: M r'c4d V/.
I understand that no later than Februant 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.
21 12
Signature: Date:
EXHIBIT
DISCLOSURE OF INTEREST
for
1906 Collins, LLC
999 Brickell Avenue, Suite 600
Miami, Florida 33131
NAME OF INTEREST HOLDER % INTEREST
1. Baoli America Group Corp.,a Florida Corporation 50%
1906 Collins Avenue
Miami, Florida 33139
MIG US, LLC, a Florida Ltd. Liability Company, Manager 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
Mathieu Massa, Manager of MIG US, LLC 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
2. MIG US,LLC,a Florida Ltd.Liability Company 50%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
Mathieu Massa, Manager of MIG US, LLC 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
TOTAL for 1906 Collins,LLC 100%