Louis Terminello/Claudia Herman SURI SOUTH BEACH, INC.
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MIAMI BEACH
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 ftLobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Terminello Louis
NAME OF LOBBYIST: (Last)
Terminello & Terminello, P:A.
J.
(First) (M.!)
2700 S.W. 37th Avenue, Miami, Fl 33133
BUSINESS NAME AND ADDRESS
(Number and Street)
(City)
(State)
(Zip Code)
(305) 444-5002
TELEPHONE NUMBER:
(305) 448-5566
FAX NUMBER:
ljt@terminello.com
EMAIL:
I. LOBBYIST RETAINED BY:
Claudia Herman. President. SURI SOUTH BEACH. INC.
NAME OF PRINCIPAL/CUENT:
D'Vine Hookah Lounge
BUSINESS NAME AND ADDRESS
(305) 444-5002
445 Lincoln Road
(Number and Street) (City)
(305) 448-5566
Miami Beach, Fl 33139
(State) (Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAlL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Claudia Herman, President
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
Claudia Herman (100%)
\
,
II. SPECIFIC LOBBY ISSUE:
Seeking variance of the required 60 seats for ulacement of R QpriPQ arnp
Issue to be lobbied (Describe in detail):
III. CI1Y AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
City of Miami Beach
Board of aili ,r l\l{)
/
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $10 ,000.00 Flat Rate
$10,000.00 FLat Rate
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":
D Yes ~ No: Are YOU lobbyina on a Dresent or Dendina bid for aoods, eauiDment or services, or on a
Dresent or Dendina award for aoods, eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes 'IXNo: Are YOU lobbyina on a Dendina aDDlication for a DeveloDment Aareement with the City or
aDDlication for chanae of zonina maD desianation or chanae to the City's Future Land Use
MaD?
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..
DYes il No: Are YOU reDresentina a not-for-Drofit corDoration or entity without sDecial comDensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST 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 EXPEND ES OR COMPENSATION DURING THE
REPORTING PERIOD.
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 ction 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI.
lOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
~duced ID ff b5r /C/O 6 2.~ 1( -{)] aCed ID
Form of Identification
VII.
SIGNATURE AND STAMP OF NOTARY:
Form of Identification
,.JI" a\. Maurilia Martinez Rego
D Personally known (Principal) ! ~ .: My Commission 00279660
~~ Of ",'of Expires January 07 2008
D Personally known (Lobbyist)
State of Florida, County of Miami-Dade
Sworn to a~ subscribed before me
This 11 day of Ju 0
E-.ONlY 2i512t ~
\) MCR J \0 ate Paid
Revised 12 08/04