Thomas J. Telesco ,rl 0
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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.
Telesco Thomas J.
NAME OF LOBBYIST: (Last) (First) (M.I)
Telesco Associates 1111 Kane Concourse Bay Harbor Isl. FL 33154
BUSINESS NAME AND ADDRESS Number and Street) ) (City) (State) (Zip Code)
305 866 1014 305 866 3317 tom @restaurant - desiqn.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
LOBBYIST RETAINED BY:
Emzon Shung
NAME OF PRINCIPAL /CLIENT:
Henrosa Hotel LLC 1400 Broadway 15th Floor NY NY 10018
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: 6 4 6 383 8 2 51 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:
Cou. i Ns nu
Historic Preservation Board Presentation for Henrosa Hotel
Issue to be lobbied (Describe in detail):
D. Pursuant to City Code Section 2- 482(g) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety with any City personnel sought to be lobbied -- further, pursuant to City Code Section
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said C
personnel' commencement of service with the City to the present date, stating the general nature of the - Obi
contractual relation.
CD 71
A) Full Name of Individual /Title B) Any Financial, Familial or Professional Relationship_
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H.P. Board None --
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $8,500.00 Flat Rate
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): $8,500.00 Flat Rate
(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 ® No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a
present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues ":
❑ Yes N No: 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 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.
❑ Yes N No: Are you representing a not - for - profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th 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 EX DITURES OR OMPENSATION DURING THE REPORTING
PERIOD.
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Signature of Lobbyist
I do solemnly swe r that all of the foregoi g facts are true and correct and th. I have read •r am familiar with the
provisions containe • Section 2-482 of the iami Beach City Code and all r •o • re. ' ements.
Signature of Lobbyist:
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification
N Personally known (Lobbyist) ® Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County • /'.. • -.: .:te of Florida, County of Miami -Dade
Sworn to and subscribe.' bef• - e orn and subscribed befor -• -
t' b Stated Florida
This 1st day of N = NO ry Publ Commission EE029720 a
`M'aUricio A Lacayo Jr T sl S t day ofNo emb r v p
dip . y Notary Public State or Florida j t' Mauricio A Lacayo Jr
. d' E "Ins 09126/2014 / I' � • < My Commission EE029720
Signatu - • ' 4 4 C Not- • - - . . natu" u '�•u: Notary — a o ' ori• _ pNes 09/26/2014 Notar' ation .f Lobbyist's signature Notariz, on o Principal's . •
TO BE COMPLETED BY CI r CLERK'S STAFF ONL
Annual Registration fee: ] Yes [ j No Amount Pl IDI4 Date Paid SSW,
Lobbyist Registration Form received and verified by: _ . _ / —
I E W
F:LCLER\ ai 1=ORMSALobbyist Registry ion F.rm i O. - oc Revised 05/05/2010
"\,,A 1 A BEAC H
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Thomas Telesco
I understand that no later than February 28th 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, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
1 11• • 0 • 1 VI ( 'c
Signature: Date: