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Jeff McInnis - TB Purdy Restaurant, LLC 1787 p Am : fAm I BEACH ;.I 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. McInnis Jeff NAME OF LOBBYIST: (Last) (First) (M.I) TB Purdy Avenue 200 East 3rd Street New York New York 10009 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-746-1105 TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Jeff McInnis NAME OF PRINCIPAUCLIENT: TB Purdy Restaurant, LLC 200 East 3rd Street New York New York 10009 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 746-1105 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: 5ee o f {— t e L - IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See Attached II.SPECIFIC LOBBY ISSUE: Z_Development Appr_ovals_and Permitting Iss uesi including, but not limited to the Historic Preservation Board, Design Review Board, Planning Board, Board Adjustment, Land Use Deve_ lopment_Committee, City Commission, and any City Workshops or Committees, if necessary, relatina to the pronertu located at --787PPurdu Avenue, Miami Beach;.Florida? 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 Staff for the Planning Department, Building Department, None. X Public Works and City administration, PB, HPB, BOA, None. X City Commission, and Mayor as necessary 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 orkciltypersonnel who is sought to be lobbied as identified on the lobbyist registration form filed. .' ;...i_ Sec 2-482(g)Any Financial, Familial or Professional Relationship . ¶j j C I "-1W0 QUIZ None. None. None_ ' f C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Regi ra • Formrevised 5-30-2012.doc • IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)Oer hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $0 per hour (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.Xlro: • • • • i•• • • . • - -1 • •.' 1 0'1 • 11.0 • • •,•:• • .• 11 . 1 • • •1 • • • •,- 1 •.1 • award for goods.eauinment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes - • • • • 41 • • 1 1 • 1• . • • • 1 • . - 11 "1 ' • =t 11 -1 . 1 - "ik • . • • • 1 • _ chance of zonina man desianation or chanae to the City's Future Land Use Mao?, 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 JIC 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 SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist 9 Y t 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 C de and all reporting requirements. • Signature of Lobbyist: C l�� Signature of Principal/Client: AC I VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: _Produced ID $-i)e3'$ le . - _Produced ID Z•■dors l/ceySa-- _ Form_of Identifi a i o _ _ _ _ _ Form of Identification YONGYI HE ► YONGYI HE Personal ��� bylllary Public,State of NewYork i _Persona_ :-rip • }' No.02HE6332301 ` f. rt. fi )'ubliC,State of NewYork ► YorkCoun ,Jr'k No.02HE6332301 VII. SIGNAT %� P l� 4 Qualified inNewYorkCounty ' . iris Otto_ber 26,20 ► ► Commission xp • Commission Expires October26,2 State of Florida, Cr uiit�rof l�liami-fade a State of Fl Sworn to and subscribe before me Sworn and subscribed efore me This q day of 2015 This '1 day of Pe< ,2015 Signature of Pu c Notary—State of Florida Signature of Public Not —State of Florida Notarization o obbyist's signature Notarization of princi l's signature TO BE COMPLETED BY CITY CLERK'S STAFF ON Y Annual Registration fee: [ Yes[ ]No Amount Pa'• $ 8 MCR# $3 7 tD¢ '7 Z Date Paid tei 5l�l Lobbyist Registration Fo received and verified by 110 A i� 1 ., • MIAMI BEACH 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: Jeff McInnis 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. April 30th, 2012, shall be Any lobbyist, who fails to file the required Statement by p , 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. • .).4( C ,./q/)5 Signat -: Date: C:\Userst clerhaiJ\AppData\LocalWlicrosoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc • A• SUPPLEMENTARY DISCLOSURE OF INTEREST Interests in TB Purdy Restaurant, LLC Percentage of Interest TB Holdings, LLC 100% 160 Greentree Drive, Suite 101 • Dover, DE 19904 Interests in TB Holdings, LLC Percentage of Interest Janine Booth 50% 160 Greentree Drive, Suite 101 Dover, DE 19904 Jeff Mclnniss 50% 160 Greentree Drive, Suite 101 Dover, DE 19904 Interests in Purdy Partners 1787, LLC Percentage of Interest Purdy Partners 1787 SRC, LLC 50% 230 Fifth Street Miami Beach, FL 33139 Purdy Partners 1787 PL, LLC 50% 1425 North View Dr. Miami Beach, FL 33139 Purdy Partners 1787 SRC, LLC Percentage of Interest Scott Robins 100% 230 Fifth Street Miami Beach, FL 33139 j.',--:-_,-1- 1 s: a tity 1 • 2/151'2015 d . 137 Miscellaneous Cash Receipt :',.-,..f,:;.1,., CITY�OF MIAMI BEACH r.;.;-:.r.,c..:-...:(7.7,21:;,';'2',.-: - _I No. , 0 Cash 0 Credit Card heck# t 12-7) C V) Zo i Received of 61111 Aici s t S C C " C. h i Address J I . ----.. For _I - P t�� --- . _ _ �-� � �.� �,� ! ? , r e f i Qc4 1 i � LAS '3- ) 'v5 i .�.Uf. c-4( ) --) 1 S SLr( (77'‘ 4nnucx\ k , e I Si b ate. t _ __ "-- - -_ _ _ Z" ..-_ _ __-._ ._ __ _ - _ -- (THIS INFORMATION MUST BE COMPLETED . � r 4 COMPLETED) � Office of Finance Director Account Number 01N- o ° f f- 1 (f Preparers �{ CQ 'Y\V '\ f Dept: "fit . !' .t� • L c i :f°1,Y ,. a. ;1.,}i 20 1.5 00 A Q.7,...7 `'` s �, ,i . � _a� �=i'2 it 00 e00 Miscellaneous Cash Receipt .. CITY OF MIAMI BEACH , -rY. ! o® Q D heck# $ 0 '. Cash Credit Card C = � n :i) C_. i c 20- Received of t l v'� A �`i 1�, , � Iv\t Address AJA _ ,- t a -- - .. For -k7 9 .. -{ 1 t-Cl y .. AA..ic__ ! a ,' a `2 ( J Ti )e:' - :`r'-. ''•`) .=,+rt. Jl f ) _ � s jik- , . _ . )....) , , ‘, ,.,_ - .. ... ,... , -'-----;,--:-.- (THIS INFORMATION MUST BE COMPLETED) Office of Finance Director o �,� r By Account Number:01 k- 6COO- )(� �-9 LI Li r Pre parer: \ Dept:_ EXT.