Charles H. Benson - Baoli Miami, LLC 1
EA MIAMIBEACH
C,O fO/O ' 4 A/3
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. •
Benson Charles H.
NAME OF LOBBYIST: (Last) (First) (M.I)
Charles H. Benson & Assoc. Architects P.A. 1665 Washington Avenue, 2n Floor Miami Beach Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
{305) 532 -6161 (305) 532 -6151
•
carkitectCaaol.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY: ,
Baoli Miami. LLC
NAME OF PRINCIPAL/CLIENT:
999 Brickell Avenue. Suite 600 Miami Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 965-7881
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: Paul Jarquin, Manager
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: See Exhibit B
II. SPECIFIC LOBBY ISSUE:
Redevelopment and conditional use permit approvals concerning 1908 Collins Avenue
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual /Title e B) Any Financial, Familial or Professional Relationship
Planning Department Staff, HPB, BOA, Planning Board and
City Commission* None , l dd t
T 4:1U S,` i..i i3
OS :110 8- AON 0 10
* Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside of a public hearing setting. / _p
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER)
A) LOBBYIST DISCLOSURE: (Required) $ '25°.00 per hour
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). OS° .00 per hour
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 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 ":
Oyes X 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 X No: Are you representing a not - for - profit corporation or entity without special compensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 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 PRECED G • DAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPE ' • C c MPENSATION DURING THE
REPORTING PERIOD.
ignature of Lobbyist
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 contain io - 82 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: • PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification
❑ Personally known (Lobbyist) ❑ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
Swom to and subscri s - e before me . Swom and subscribed before me
This . i∎ • ay o '
! t. ' 20j0 This day of , 20_
Signature of ' Notary - , .4. FGI JAKONIUK Signature of Public Notary — State of Florida
Notarizatio of Lobbyist'- - , AMY cOMMIS510N # DD825551 Notarization of Princi al's signature
IRES: November 16, 2012 P g
°F }..o *�v Fl Naen D
t w� ifwunt Assoc. o Cs.
` 0 - SE ONLY p // �1
Annual Registration fee: [ ] Yes [ ] No Amount Paid MCR # 3 1S ate Paid (( r0 ./ / v
Lobbyist Registration Form received and verified e , / Entered By: ///
F: \CLER \$ALL \MARIA -M \Lobbyist \LOBBYIST fORM 05.doc / //' �� !) • Revised 12/08/04
■
■
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER)
A) LOBBYIST DISCLOSURE: (Required) $ 2 5 0 ,00 per hour
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 2 .00 per hour
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 ":
0 Yes X No: Are you lobbying on a present or pending bid for goods. equipment or services. or on a
present or vending 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 ":
OYes X 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..
P Yes X No: Are you representing a not - for -profit corporation or entity without special compensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 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.
CC.kal exASar,I
Signature of Lobbyist
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 Section 2 -482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist: CC-kkr tkS fienSorC
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification
❑ Personally known (Lobbyist) ersonally known (Princ • aleso oo, Notary Public State of Florida
(; Mitchell S Polansky
VII. SIGNATURE AND STAMP OF NOTARY: r g My Commission 00770240
ov, o° Expires 04/02/2012
State of Florida, County of Miami -Dade State of Florida, County of iami -ia•e
Sworn to and subscribed before me Sworn and subscri r-d before me
This day of , 20_ This 2- day of .! _! 20jO
Signature of Public Notary — State of Florida Signature of Publi 14 . ry tate of Florida
Notarization of Lobbyist's signature Notarization of r cip ,'s • • nature
FOR CLERK'S U E O�1 4Y 9
Annual Registration fee: [ ] Yes [ ] No Amount Paid S MCR # ‘)776 Date Paid It 9 /
Lobbyist Registration Form received and verified by: 40 . Enter By:
F: \CLER \$ ALL \MARIA- M \Lobbyist\LOBBYIST FORM 05.doc �� r f Revised 12/08/04
MIMAIBEACH
nuF
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:
(. I . ben cOn
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.
Signature: Dat :
EXHIBIT B
DISCLOSURE OF INTEREST
for
Baoli Miami, LLC
999 Brickell Avenue, Suite 600
Miami, Florida 33131
NAME OF INTEREST HOLDER % INTEREST
1. Baoli America Group Corp., a Florida Corporation 50%
Christophe Caucino, President
1504 Bay Road, Apt. # 1117
Miami Beach, Florida 33139
a. Christophe Caucino 50%
1504 Bay Road, Apt. # 1117
Miami Beach, Florida 33139
b. Pierre Antoine Navarro 50%
27 Blvd Mont Fleury
06400 Cannes - FRANCE
TOTAL for Baoli America Group Corp. 100%
2. JPRE, LLC, a Florida Limited Liability Company 50%
REI Holdings, Manager
999 Brickell Avenue, Suite 600
Miami, Florida 33131
a. REI Holdings, a Florida Fictitious Name 50%
Paul Jarquin, Owner
999 Brickell Avenue, Suite 600
Miami, Florida 33131
i. Paul Jarquin 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
TOTAL for REI Holdings 100%
b. MIG US, LLC, a Florida Ltd. Liability Company 50%
Mathieu Massa, Manager
1504 Bay Road, Apt. #916
Miami Beach, Florida 33139
i. Mathieu Massa 100%
1504 Bay Road, Apt. #916
Miami Beach, Florida 33139
TOTAL for MIG US, LLC 100%
TOTAL for JPRE, LLC 100%
TOTAL for BAOLI MIAMI, LLC 100%
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