Donald Washburn - Bagatelle Miami LLC 2000 cd 1,Nr, Aue,
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.
Washburn Donald
NAME OF LOBBYIST: (Last) (First) (M.I)
The Audio Bug, Inc. 3800 Hillcrest Drive, Unit 102 Hollywood, FL 33021-7937
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(954) 983-2788 (954) 983-2789 AUDIOBUGl@aol.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, ore-mail address.
I. LOBBYIST RETAINED BY:
Bagatelle Miami LLC
NAME OF PRINCIPAL/CLIENT:
411 W. 14th St. NYC NY 10014
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
917.292 .1880
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2.482(c)]
• NAME QF CHIEF OFFICER,PARTNER,OR BENEFICIARY:
Remi Laba Ludovic Bricks, Authorized Representative
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: Sc Ct?rro.c)le
II.SPECIFIC LOBBY ISSUE:
General representation re 2000 Collins Ave. , including but not limited to
Issue to be lobbied(Describe in detail): Conditional Use Permit matters.
ill.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 X
Planning Board
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or pfotressional
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
—None
eaj
F:\CLER1$ALLIaFORMSILOBBYIST FORMS\Lobbyist Registration Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $2,700.00
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). $2700
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 ou lobb 'n• on a •resent or •endin• bid for •oods e.ui•ment or services or on a •resent or •-ndin s
award for goods,equipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
—Yes XNo: 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 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.
_YesX No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
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
THE PRECEDING CALENDAR YEAR. A STATEMENT SHA BE FILED EV IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
irwAg . 14,--arA...._____
Signature of Lobbyist
I do solemnly swear that all • he foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Mia :-ach City C,.•: nd -II '-porting requirements.
Signature of Lobbyist: / /40,, „ iL jj/0
41M1111111/411111111W ,
Signature of Principal/Client: _ M11197f/14-=:'
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
ondc4 cowers 1 ece "o VProduced Produced ID � � �� V Produced ID ���r�t�l� LAY►\/e���, ���,�►,
Form of Identification o Form of Identification .,,,,,, ••;°r
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Personally known(Lobbyist) 09104• 0<% Personally known(Principal) '.�;,aq.•;.`0�'
VII. SIGNATURE AND STAMP OF N TARY: ,,f o
+S to....bird O o n a,
State of Florida,County of „o �. ® State of Florida,County of Miami-Dade 3 3 ' a
Sworn to d sub-. -• before me c o>t Sworn and su•scribed before me H • Q
This •: Of 1J ♦ o x ei C
I Y 1. u 01� Pi, if cD This ci of Ativew iece,2018 z mi. Ni.L I Aft.ILA.....:4 I -^ E te a
Signature of Pu:'
A Aid allikegiO SD —1.ry–S e of Florida `c p Signature of Public o._ S e of Florida co ; 2 o
Notarization of Lobbyist's signature - A: Notarization of Principal's signature o �'
TO BE COMPI,TIMQ BY CITY CLERK'S STAFF ONLY 0.
Zoe ia,
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ �0 3\�MCR ' 5 Date Paid 1!! 7 1 "
Lobbyist Registration Form received and verified by: w C _ i;
F.:\CLER$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registr in Forni.doc Revi 01/22/2014
F:\CLER1$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
,
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: Don Washburn
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 of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed the Miami-Dade County Commission on Ethics and Public Trust.
did da-aia,
Signature: Da e:
F:\CLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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Have a nice day!
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EXHIBIT B
DISCLOSURE OF OWNERSHIP
Bagatelle Miami, LLC (Managing Member: Bagatelle Miami Management, LLC)
Name Percentage
Bagatelle Miami Management, LLC 100%
Bagatelle Miami Management, LLC (Managers: Remi Laba and Jonathan Segal)
Name Percentage
Bagatelle Miami Investors, LLC 82.1%
The One Group, LLC 2.1%
RCI II, Ltd. 5.26%
' Elena Baybakova 5.26%
Fred Contini* 5.26%
*Note: Not yet finalized.
Bagatelle Miami Investors, LLC (Managing Member: Bagatelle America, LLC)
Name Percentage
Bagatelle America, LLC 92.9490%
Anthony Abenante 0.3205%
RK Lures, LLC 0.3205%
EMC Fifth LLC 2.2435%
All Rounder LLC 0.3205%
Mark A. Standish 0.6410%
Maria Rosaria Ciavolino 0.6410%
Okan Aksel 0.6410%
Richard Tavoso 0.9615%
Tavarva Investments LLC 0.3205%
John Ripley 0.3205%
T. Butkiewicz 0.3205%
The One Group, LLC
Name Percentage
The One Group Hospitality, Inc.* 100%
*Publicly traded company
RCI II, Ltd.
Name Percentage
Beneficiary, Allison Myeroff 33.3%
Beneficiary, Alexa Segal 33.3%
Beneficiary, Sharon Segal 33.3%
Bagatelle America, LLC (Managers: Jonathan Segal,Nick Giannuzzi, Remi Laba and
Aymeric Clemente)
Name Percentage
HIP Hospitality, LLC 50%
In the Buzz LLC 50%
RK LURES, LLC
Name Percentage
Christopher Lindsey 100%
EMC Fifth, LLC
Name Percentage
Edward McBride 100%
All Rounder LLC
Name Percentage
Mussadiq Lakhani 100%
Tavarva Investments LLC
Name Percentage
Shawn Rubin 100%
HIP Hospitality, LLC (Manager: Jonathan Segal)
Name Percentage
Jonathan Segal 85%
Sam Goldfinger 5%
Celeste Fierro 5%
Nick Giannuzzi 5%
In the Buzz LLC (Managers: Remi Laba and Aymeric Clemente)
Name Percentage
Aymeric Clemente 50%
Remi Laba 50%