Ethan B. Wasserman - Shore Clubera M!AMfBEACH
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.
NAME OF LOBBYIST: (Last) (First) (M.1)
CLVSJ 4— 'Qow., Lt_e 1=L /711I
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or a -►nail address.
t. LOBBYIST RETAINED BY:
NAME OF P�CIPAUC s L S
NT: L & /L( r1 r` CI
WE
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
r PL
(State)
33135
(Zip Code)
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:
u.S:P.ECIFI.C:_LOB:BY ISSUE:
3 How t e7V.c
Issue to be lobbied (Describe in detail):
111. 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 he general nature of the subject contractual relationship.
Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any,.144ir5gss3 financialOamiiial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city comniissioneriot (ty p rsonnei who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) An Financial, Familial or Professional Retationshi• ` 1 / 9 9i_IP
Sec 2- 482(a)(4) Full Name of Individual and
title of person to be lobbied
Contractual Relationship (Explain)
YES
NO
Air(
�y i.cJ pa C ft 4�,,„ c
w) i j
/
/
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V
Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any,.144ir5gss3 financialOamiiial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city comniissioneriot (ty p rsonnei who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) An Financial, Familial or Professional Retationshi• ` 1 / 9 9i_IP
� 1'
'
F : \CLER \BALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) n /'.' /1„ti
8) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): /1 r /I ,
(Required). b < �t
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
2)
€Yes No: Are ou Iobb in. on a .endin. a. placation fora Development A.reement with the Cit or a..lication 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
itegt, shall register with the clerk as required by this section but, shall not be required to pay any registration fees.
o: Are ou lobb in on a .resent or •endin bid for .00ds equipment or services or on a .resent or .endin
award for goods, equipment or service?
Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues ":
€ Yes o: 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 EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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:
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION:
2roduoed ID F L- I
Form of Identification
€ Personally known (Lobbyist)
Vll. SIGNATURE AND STAMP 0
State of Florida, County of Miami -Dade
Sworn to and subscribed • - . e . e
This /C7 of `f 2011
Signature o! Public Notary — State of Florida
iiiiii ISABEL SATCHELL
; ; MY COMMISSION It DD 87969i
EXPIRES: April 13, 2013
{ ' ^•.J>'• .zoo`;
' • !boded Thai Notary Public Underwriters
Notarizati•n of Lobbyist's signature
PRINCIPAL IDENTIFICATION: it-- /kProduced ID PL L/J�+v'e 2
Form of Identification
€ Personally known (Principal)
State of Florida, County of Miami -Dade
rn and subscribe b- or me
�!) day o ' �f , 2011
Signatu a of Public Ndfary — State of Florida
Notari ation of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ] Yes [ ] No Amount Paid $ MC # ' � / Date Paid
Lobbyist Registration Form received and verified by:
F: \CLER \$ ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
'orm.doc Revised 1/11/2011
A�%t -,l y,
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeochfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: tc.--
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.
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
appealed to the Miami -Dade County Commission on Ethics and Public Trust.
Signature:
F: \CLBR \$ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
Date:
DISCLOSURE OF INTERESTS
The Shore Club, located at 1901 Collins Avenue, Miami Beach, Florida, is owned by Philips
South Beach, LLC, which in turn is owned as follows:
I. Ninety-three and twenty -one hundredths percent (93.21 %) of Philips South Beach LLC
is owned as follows:
1.00% SB Realty Corp., which in turn is owned as follows:
90.00% Philip Pilevsky
417 Fifth Avenue
New York, NY 10016
10.00% Sheila Levine
417 Fifth Avenue
New York, NY 10016
36.04% Philips SB Associates, LLC, which in turn is owned as follows:
90.00% Philip Pilevsky
41.7 Fifth Avenue
New York, NY 10016
10.00% . Sheila Levine
417 Fifth Avenue
New York, .NY 10016
56.17% Clark SB lI, LLC, which in turn is owned as follows:
3.32% Jonathan A. Bernstein
993 Park Avenue
New York, NY 10028
96.68% Clark SB, LLC, which in turn is owned as follows:
32.05% The Clark Foundation
One Rockefeller Plaza
New York, NY 10020 -2102
(this is a 501(c)(3) charitable foundation)
Directors/Members:
Kent L. Barwick
Felicia H. Blum
e'
Jane Forbes Clark
William M. Evarts, Jr.
Gates Helms Hawn
Archie F. MacAllaster
Joan S. McMenamin
Kevin S. Moore
Thomas Q. Morris
Anne L. Peretz
Edward W. Stack
John Hoyt Stookey
Alexander F. Treadwell
Clifton R. Wharton, Jr.
25.64% James F. Clark
c/o The Clark Estates, Inc.
One Rockefeller Plaza
New York, NY 10020 -2102
15.38% The Scriven Foundation
One Rockefeller Plaza
New York, NY 10020 -2102
(this is a 501(cX3) charitable foundation)
Directors/Members
Robert G. Campbell, M.D.
Jane Forbes Clark
Edward Gozigian
J. Michael Moffat
Kevin S. Moore
Thomas Q. Morris, M.D.
Marian G. Mullet
Edward W. Stack
7:05% . Trust for. Anne Peretz, 1944
c/o The Clark Estates; Inc.
One Rockefeller Plaza
New York, NY 10020 -2102
Income beneficiary:
Anne Peretz
• •
Residuary beneficiaries in equal amounts:
Jesse Peretz
Evgenia Peretz
David Farnsworth
Anne E. Farnsworth
(addresses for each are set forth below)
3.21% Trust for Martin Peretz, 1976
c/o The Clark Estates, Inc.
One Rockefeller Plaza
New York, NY 10020 -2102
1.28%
Income beneficiary:
Martin Peretz
Residuary beneficiaries are:
50% in equal amounts to:
Jesse Peretz
Evgenia Peretz
David Farnsworth
Anne E. Farnsworth
(Addresses below)
50% To charities to be designated
David L. Farnsworth
9 Brantwood Road
Arlington, MA 02476
1.28% Anne E. Farnsworth
4001 Virgilia Street
Chevy Chase, MD 20815
1.28%
Jesse W. Peretz
533 Canal Street
Unit 3
New York, NY 10013
1.28% Evgenia Peretz
171 Duane Street
No. 2
• •
5.13%
3.85%
1.03%
New York, NY 10013
Edmund S. Twining III
P. 0. Box 8
Driggs, Idaho 83422
Eve C. Labouisse
1 Sutton Place South
New York, NY 10022
Edward W. Stack
25 Waverly Street
Glen Head, NY 11545
0.515% Kevin S. Moore
79 Norfield Road
Weston, CT 06883
0.51% Richard C. Clarkson
24 Roxbury Road
Garden City, NY 11530
0.515% Anne B. Moore
418 East 59th Street
#24A
New York, NY 10022
II. The remaining six and seventy -nine hundredths percent (6.79 %) of Philips South Beach,
LLC is owned as follows:
100% Hotel Parent LLC, which in turn is owned as follows:
80.38% NorthStar Hospitality LLC, which in turn is owned as follows:
100% NorthStar Partnership L.P. which is in turn owned as
follows:
73.34% NorthStar Capital Investment Corp.
527 Madison Avenue, 16th Floor
New York, NY 10022, which
in turn is owned as forth on
Exhibits "A" and `B" attached hereto
• •
9.44% Sorco Interfund LLC
Sorco Fund Management
888 7th Avenue
New York, NY 10022
8.43% NorthStar Operating LLC, which in
turn is owned as follows:
48.58% David Hamamoto
527 Madison Ave
16th Floor
New York, NY 10022
• 48.58% W. Edward Scheetz
527 Madison Ave
16th Floor
New York, NY 10022
L58%
David G. King Jr.
527 Madison Ave
16"' Floor
New York, NY 10022
0.36 %p Peter W. Ahl
527 Madison Ave
16th Floor
New York, NY 10022
,0.22% Marty Lamb.
527 Madison.Ave
16th Floor
New York, NY 10022
0:22% Keith Meister
527 Madison Ave
16th Floor
New York, NY 10022
0.08% Greg Peck
527 Madison Ave
16th Floor
New York; NY 10022
0.11%
Adam Anhang
527 Madison Ave
16th Floor
New York, NY 10022
. 0.11% Charlie Humber
527 Madison Ave
16th Floor
New York, NY 10022
0.08% ' Harriet Z. Stamatakos
• 527 Madison Ave
16th Floor
New York, NY 10022
0.06% Glenn Levin
527 Madison Ave
16th Floor
New York, NY 10022
0.02% Denise Olsen
527 Madison Ave
16th Floor
New York, NY 10022
4.83% NorthStar Capital Partners LLC,
which in turn is owned as follows:
50% David Hamamoto
527 Madison Ave
16th Floor
New York, NY 10022
50% W. Edward Scheetz
527 Madison Ave
16th Floor
New York, NY 10022
2.25% DB Alex Brown Exchange Fund II
L.P.
DC Investment Partners
10 Burton Hills,' Suite 120
Nashville, TN 37125
• 1
0.88% DB Alex Brown Exchange Fund I
L.P.
DC Investment Partners
10 Burton Hills, Suite 120
Nashville, TN 37125
0.33% David G. King Jr.
527 Madison Avenue, 16th Floor
New York, NY 10022
0.29% Marc S. Gordon
527 Madison Avenue, 16th Floor
New York, NY 10022
0.10%
Richard J. McCready
527 Madison Avenue, 16th Floor
New York, NY 10022
0:08% Peter W. Ahl
527 Madison Avenue, 16th Floor
New York, NY 10022
0.02% Richard Sabella
527 Madison Avenue, 16th Floor
New York, NY 10022
0.01% . Kevin Reardon
527 Madison Avenue, 16t Floor
New York, NY 10022
19.53% RSA Associates, L.P., which in turn is owned by the Ian Schrager
family entities listed below, as follows:
0.781609% RSA GP Corp. (General Partner)
475 10th Avenue
New York, NY 10019
7.579319% Ian Schrager (Limited Partner)
475 10th Avenue
New York, NY 10019
11.400956% RSA New York Associates, LP (Limited •
Partner)
475 10th Avenue
New York, NY 10019
0.238116% RSA New York Corp. (Limited Partner)
475 10* Avenue
New York, NY 10019
65.00% RSA Family Holdings, LLC (Limited Partner)
Managing Member: Ian Schrager
Non - Managing Schrager Family 1999
Trusts UTA dated
August 29, 1999,
Trustees: Ian Schrager
and Rita Schrager,
47510"' Avenue
New York, NY 10019
15.00% ISB Family Holdings, LLC (Limited Partner)
Managing Member: Ian Schrager
Non - Managing: Schrager Family Spray
Trust UTA dated Sept.
29, 1999
Trustees:Bemard
Schrager
And Stuart Kotler
475 106 Avenue
New York, NY 10019
0.09% By the following Philip Pilevsky entity:
Century Operating Associates
475 106 Avenue
New York, NY 10019
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