Don Washburn - Scott Duffner (Yard House, Inc) I
_ MIAMI BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM lle
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.
Washburn Don
NAME OF LOBBYIST: (Last) (First) (M.1)
The Audio Bug, Inc. 3800 Hillcrest Drive, #102 Hollywood Florida 33021
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
954-983-2788 954-983-2789
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
I. LOBBYIST RETAINED BY:
Yard House USA, Inc. (Scott Duffner,Vice-President)
NAME OF PRINCIPAL/CLIENT:
Yard House Restaurants 7700 Irvine Center Drive,Suite 300 Irvine California 92618
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(949)727-0959,ext. 1103 (949)727-0831
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME OF CHIEF OFFICER, PARTNER,OR BENEFICIARY: Publicly traded on the NYSE under the symbol MAR.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: Publicly traded on the NYSE under the symbol MAR.
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II. SPECIFIC LOBBY ISSUE: _<
M C `n
Development approvals for Yard House restaurant at 1681 Lenox Avenue r r—
Issue to be lobbied (Describe in detail): z ��
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: CD
� N
Pursuant to City Code Section 2-482(a)(4)include the commissioner of personnel sought to be lobbied,and Zetla thelobbyist
has entered into contractual relationship(paid or unpaid)with said city commissioner or personnel from 12�,YpntFpreceding
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 Staff,City Administration None X
DRB, BOA, Planning Board,City Commission None X
Pursuant to City Code Section 2-482(g)Every registrant shall be required 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 current city commissioner
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
None. �^
_ 7
IV. DISCLQSURE OF TERMS AND OUNTS OF LOBBYIST COMPENSATION(DISC E WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) $4,000
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $4,000
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 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 2-4 the Miami Be h Ci Code a/nd/al. reporting requirements.
Signature of Lobbyist:
� �� �
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: •N1 PRINCIPAL IDENTIFICATION:
n
❑ Produced ID o � ❑ Produced ID
Form of Identificati 4�A•?� Form of Identification
MMOZ
X•c —•o
Personally known (Lobbyist) 0= fir ❑ Personally known (Principal)
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VII. SIGNATURE AND STAMP OF NOT Q)
O 3 0 -
State of Florida, County of Miami-Dade L"m M State of Florida, County of Miami-Dade
Sworn nd subscrib d efore me n' Sworn and subscribed before me
Thi y Of , 2011 A a This day of , 20_
d
Signa u of Public Not —State of Florida Signature of Public Notary—State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR,CL�RK'S USE ONLY/ /� �Annual Registration fee: [ ]Yes[ ] No Amount Paid s�i' MCR# , Date aid
Lobbyist Registration Form received and verified by: Entered By:
Revised 1/11/2011
I
State of California ) CALIFORNIA ALL-PURPOSE
County of Ord ) CERTIFICATE OF ACKNOWLEDGMENT
On y�/' , 2D�2 before me,
(here insert name and title of the officer)
personally appeared SC.O
who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s)acted,executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the LINDA D KEITH
COMM. #1942343 =
State of California that the foregoing paragraph is true and correct. Notary Public - ifornia o
0 0 unity 15
WITNESS my hand and official seal.
Signature
W'
(Seal)
OPTIONAL INFORMATION
Although the information in this section is not required bylaw,it could prevent fraudulent removal and reattachment of this
acknowledgment to an unauthorized document and may prove useful to persons relying on the attached document.
Description of Attached Document Additional Information
The preceding Certificate of Acknowledgment is attached to a document Method of Signer Identification
titled/for the purpose of Proved to me on the basis of satisfactory evidence:
Lo form(s)of identification O credible witness(es)
Notarial event is detailed in notary journal on:
containing pages,and dated Page# Entry#
The signer(s) capacity or authority is/are as: Notary contact:
❑ Individual(s) Other
❑ Attorney-in-Fact ❑ Additional Signer(s) ❑ Signer(s)Thumbprint(s)
❑ Corporate Officer(s)
Title(s) ❑
❑ Guardian/Conservator
❑ Partner-Limited/General
❑ Trustee(s)
❑ Other:
representing:
- Name(s)of Person(s)or Entity(ies)Signer is Representing
O Copyright 2007 Notary Rotary,Inc.925 29th St.,Des Moines,IA 50312-3612 Form ACK03. 10/07. To re-order,call toll-free 1-877-349-6588 or visit us on the Internet at http://www.notaryrotary.com
I
C001;'m r--d— Revised 04/27/2012
City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139, www.miamibeachfi.gov
CITY CLERK Office
Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: -b 0 na W ouc J b o rr l
I understand that no later than February 28 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, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist(or principal) who
fails to timely file a Statement and in addition to any other penalties which may be
imposed as provided in Section 2-485.1, a fine of$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist (or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
Signature: 611 6ate:
C:\Users\clerhatMppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc