Robert Kerr - Mark Shemel /\AIAMI BEACH
o
City of Miami Beac h 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.
Kerr Robert
NAME OF LOBBYIST: (Last) (First) (M.I)
Kerr-Tek Design, Inc. 1172 South Dixie Highway, Ste. 424, Coral Gables FL 33146
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-321-2085 robert(fterdekdesion.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:
Mark Shemel
NAME OF PRINCIPAUCLIENT: _ °
Collins Park Hotel, LLC 236 21 Street Miami Beach Florida 33139 _<
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (ZTp Code)-, c- 'n
(516)526-9620 r co-)
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] U. -�
CD
• NAME OF CHIEF OFFICER,PARTNER;OR BENEFICIARY: I„UV,-SV Q_4W A -`Y
w' ,. "
-- D
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: WAW-V d -
ii.SPECIFIC LOBBY ISSUE:
Development Board Approvals for South Beach Hotel-236 21 Street, Miami Beach, Florida 33139
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 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
Planning Department and Building Department Staff None X
B,HPB, BOA, City Commission, as necessary* None X
Pursuant to City Code Section 2.482(8)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(8)Any Financial,Familial or Professional Relationship
C:\Users\clerhatl\AppData\Local\MicrosoftlWindows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
o
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
B)PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED).
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 lobbvina on a present or oendina bid for good s.eauinment or services,or on a present or
gig award for goods,gauipment or service?
2) Pursuant to Miami Beach City Code Section 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
fgj change of zoning map designation or chanae to the City's Future Land Use Man?
3) Pursuant to Miami Beach City Code Section 2-482(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 renrgsenting.a not-for-profit corporation or entity without Special cnmpancatien or reimhurspment_
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 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
IHE nQEQEDING CALENDAR YEAR A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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 City Code and all reporting requirements.
Signature of Lobbyist: _
Signature of Principal/Client:_
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ,
Z �N
Produced ID_ _ _Produced ID- Al Y5 Li a.-1,5 e W z 2� >
Form of Identification Form of Identification 0- m oa l
ASV M _Lb
Personally known(Lobbyist) _ _Personally known(Principal) )o '
VII. SIGNATURE AND STAMP OF NOTARY: t--o-ZS to
Alew)Ok Al 9W Yiei k z 3 N
State of Florida,County of Miami-Dade State of e,County of i" ade c a�
Vi
Sworn to and subscribed before me Sworn and subscribed before me Z O
This_ -day of_ ,2013 This_ 1 3 day of_ c/w3f ,2013
Signature of Public Notary-State of Florida Signature of Public Notary-State of Feria
Notarization of Lohbyi�signature Notarization of Principe signatu/re
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$_ MCR#_ —Date Paid _ Lobbyist Registry
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
Corporate Disclosure
South Beach Hotel
100% owned by Collins Park Hotel LLC
Agent: Mark Shemel
236 21st St
Miami Beach, FL 33139
Collins Park Hotel LLC owned by:
Percent
Ownership Owner Address
7272 Wurzbach Road, Suite 902 San Antonio, Texas
51 Lidia Chavez 78240
20 Steve Shemel 109 West 27th Street 9th floor New York, NY 10001
7 Durga Edson 10 Norden Lane, Huntington Station, NY 11746
5 Ronald Aboody 959 Scioto Drive Franklin Lakes, NJ 07417
5 Kirk Gellin 1375 Broadway 2nd Floor New York, NY 10018
5 Jon Amani 66 powerhouse road, Roslyn, NY 11577
3 Chandru Mahtani 1385 Broadway, New York, NY 10018
2 Mark Shemel 109 West 27th, 9th Floor, New York, NY 10001
1 Shawn Vardi 2155 Washington Court, Apt 503, Miami Beach, FL
33139
1 Hunter Gellin 1375 Broadway, 2nd Floor, New York, NY 10018
100
'v
F:\CLE istration Form.doc Revised 04/27/2012
M I
_ 1. A.0
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Rafael E.Granado, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 , Fax:305.673.7254
LOBBYIST NAME: Robert Kerr
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
apps he Miami-Dade County Commission on Ethics and Public Trust.Ito .15
natu Date:
C:\Users\cierhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc