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Donald Washburn - TB Purdy Restaurant, LLC t7eT7 , Ave 11 1 �D E H City of Miami Beach Office of the City Clerk" 1700 Convention Center Drive, Miami Beach, FtL 3?.. 9. 5 p : 12 LOBBYIST REGISTRATION FORM -� _ r ;_ I�I S 4k �':I_r .I i 1 14 �. Imo.! �� l.:��. 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 Florida 33021 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 954-983-2788 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: • 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: ,Development Approvals and Perzn tting sues, 'ncluding, but not limited to the Historic Preservation Board, Design Review oard,P1'anninng Board, Board of Adjustment- d Use De m_enLCommittee, City Commission, and any City Workshops or Committees. if necessarutt.relatina o the property located at 1787 Purdu Avenue, Miami Beach. Florida Issue to be lobbied(Describe in-detail): -- 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 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 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. None. . None. � 4 C:\Users\clerhati\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist R-'is -a on 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)$ S©cx , B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):$ c�G O (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 XNo: i - • • • • 1 • •1 - • • , •-1 • • • • • •,•,. =;• .• 11 1 • - I C - • •1 - :4, - 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 XNo: Are you lobbying on a nendina anpilcation for a Development Agreement with the City or annlication for chance of zoning man desianation or change 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 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 • ' •ENSATION RECEIVED_ IN THE CITY OF MIAMI BEACH E Q.a • • : 1 1 I ►.I : 1 i 11 1 ■ 4• , •' ■ .'I : ■ - 1 1 0 EXPENDITURES OR • ,i • ■ i • 1 1 1 • : k Cam: • 1 44 v /-......J / ��� Signature of Lobbyist I do solemnly swear that all • e foregoin• facts a - true a d correct and tha ave read or am familiar with the provisions contained in Section 2-482 of the Mia ch City.••••••e/:n. - rep *n requirem is Signature of Lobbyist: 1114 4 Signature of Principal/Client: /t C /` VI. LOBBYIST IDENTIFICAT PRINCIPAL IDENTIFICATION: _Produced ID Produced ID c)r)e.€r4 (1 rea L Form of Identification .c oo __ =`^^^ alealifi^a*_ _== , , 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: Donald 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, 2012, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appeale o the Miami-Dade C unty Commission on Ethics and Public Trust. n 4) , gt--J-14---- zafiii((-C Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outtook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc 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%o 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 :., 7-1 't.k.-,t. o 2'r7:, ^'l l t z 001 11',? Miscellaneous Cash Receipt CITY OF MIAMI BEACH:i:) No. 0 Cash I Credit Card 91bheak#_ 10 $ 7 d- a 15,//5 20 /5 Received of ¢f"I ch\r. E-4 t; h b u r Address -3'IS toO 1-\ 1\ - r Dr s , :-I= I o ii o_t{ i (,tt"s''�'1 �i� �1'a... ��� � �• ..off l��.e'..SL�I.�G� F.... For ) ? Y w-c 1 e,4`1 i -: /11,-to 1, I'-kt r,_.�_r . t t (1) - f .3 5 t t o �, (THIS INFORMATION MUST BE COMPLETED) Office of Finance Director. £ By • Account Number 0 =i 1 , .:czO O • 3w Li i Li Pre Parer: )fr.5()k `- A''1.,1I1-I-P Det: °} ( Ic_r k EXT: .i t ,:....- � -_-.,. a�---f'. �•-''L--., s.,i.�..-..<�_....'_.�.;,.-: -.�..c-.--.,. .- -_ -. - - - ..-r. .. � _- 1-,w. _•- -c...... '-L'�' - _•�t.--