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Monika Entin - Gabriel Halimi MIAMI BEA H 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. Entin Monika NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (05)374-5300 (305)377-6222 mentin(a-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: Gabriel Halimi NAME OF PRINCIPAUCLIENT: Umami Burger,LLC,a California Company 7966 Beverly Blvd.,First Floor Los Angeles CA 90048 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (323)782-8201 (323)782-8202 gabriel.halimi(d)-umami.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: Gabriel Halimi • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,PARTNERSHIP OR TRUST: Please see the attached. ll.SPECIFIC LOBBY ISSUE: Development approvals and permitting issues related to 1070-1080 Alton Road. Issue to be lobbied(Describe in detail): lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered into any 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 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied Tanning Department, Building Department and Public None Works Staff B, DRB, HPB, BOA, FP, City Commission, as None necessary* 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(g)Any Financial,Familial or Professional Relationship a i~, (,,,,44 `J None rN n F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc CSI j IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$310.00.per hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $310.00 per hour 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 oresent or pending bid for goods.equipment or services.or on a present or pending award for goods,eauipment or service? A. 2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes X Now Are you lobbying on a pending aoolication for a Development Agreement with the City or aoolication for change of zoning map desianation or change to the City's Future Land Use Mao? 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 representina a not-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 281h 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 EM EXPENDITURES OR Signature of Lobbyiuv- I do solemnly swear that all of the foregoing facts are a and correct and that ve read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code an all reporti quirem nts. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID S+�''ro� Produced IDDr. �+cm6t- 31``005.55-CA Form of Identification Form of Identification K. fern onally known(Lobbyist) m C 4 Z Personally known (Principal)VII. °f SIGNATURE AND STAMP OF �p ? M c NOTARY: o . ' n See State of Florida, County of Miami-Dade C"o State of Florida, County of Miami-Dade Sworn d subscnb of re e N ;; Sworn and subscribed before me This ay ofA 2013 A Q his day of ,2013 Vil i'llil Sig a re olVdbric otary—State of Florida Signature of Public Notary—State of ReFida CALI r-02N I A Notarization of Lgbsignature Notarization of Principal's signature TO BE COMPLETED B`Y�CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date P d '� 3 Lobbyist Registration Form received and verified by: NO TAR YPUBLIC JURAT CERTIFICATE STATE OF COUNT( OF S es Subscribed and sworn to (or affirmed) before me on this day of VebrtAQY- 201 , by Gnbr--iel Holimi proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. r a P `etc AUFM Signature of Notary Public 'W, law Notary Seal OPTIONAL ENTRIES Type or Kind of Document: Name of Other Party(ies) Involved: Date of Document: No. of Pages: Type of ID. Used: Additional Notes: E L QI ON N 1� - O � z E U Sample Oath Wording:Do you swear that the statements in this document are true so help you God? © 2008 ALL RIGHTS RESERVED - AMERICAN NOTARY GROUP - AmericanNotary.com - Reorder at: (323)349-0860 /\AIAMI BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beacli,Florida 33139,www.miamibeachll.eov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 ,Fax:305.673.7254 LOBBYIST NAME: Monika Entin 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. 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 t Mia TH-Dr de-C.pu`nty Commission on Ethics and Public Trust. ac) Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc i i I k " t :� ;j 114-� -- t I t, W a ` W .: .0 V - a �+ 4) 'a V �� V � � ca 02 v ._,-j L w wo cc N V .� 4L" z o r ❑ C V 4 CL aim . i