Michael J. Marrero - Don Peebles � { � /�
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City of Miami Beach Office of the City Clerk s�3
1700 Convention Center Drive, Miami Beach, FL 33139 y
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.
Marrero Michael J.
NAME OF LOBBYIST: (Last) (First) (M.1)
Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Miami, Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 374-5300 (305) 377-6222 mmarreroa-brzoning law.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Don Peebles
NAME OF PRINCIPAL/CLIENT:
Bath Club Entertainment, LLC 550 Biltmore Way, Ste. 970 Coral Gables, Florida 33134
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 442-4342 (305) 442-4345 peeblesl(d)-aol.com
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:Don Peebles
i
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INT EST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: So e� tz I
ii.SPECII=IC LOBBY ISSUE:
Board of Admustment A eal regarding Use of Pool Deck and Facilities
Issue to be lobbied(Describe in detail):
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 relationshi .
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Commission, Planning Staff, Development Boards NONE
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or p ssiq
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city person o is
sought to be lobbied as identified on the lobbyist registration form filed. Vol',
Sec 2-482(g)Any Financial, Familial or Professional Relationship
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):$395.00
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):$395.00
(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 X No: Are you lobbvina 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes X No: Are you lobbying on a pending application for a Development Aareement with the City or application for
change of zoning map designation or change to the City's Future Land Use Mang
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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH
EM THE PRECEDING CALENDAR YEAR, A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REP ER1011 -
Signature of Lo byist
I do solemnly swear that all of the foregoing f cts are true an�dd _rect and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach City C de eportiquirements.
Signature of Lobbyist:
Signature.of Principal/Client: �"Zut_&C_
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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Form of Identification °+„a.,c Form of Identificatio .°0
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VII. SIGNATURE AND STAMP OF NOTARY: 'a'0 °
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State of Florida, County of Miami-Dade N m State of Florida, County of Miami-Dade cc
Sworn to and subscribe before me N Sworn ci subscribed A m
T y of tWL4V-,2012 co 0 This day of ,2012
Sig ature of Public Notary—State of Florida Signature of Public otary—State of Florida
Notarization of Lobbyist's ignature Notarization of Principal's signature
TO BE COMPLETED By CITY CLERK'S_ ST F QN Annual Registration fee: Paid$ ` MCR# Y p
,Yes DatVqaid r
Lobbyist Registration Form received and verified by:
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F!�ct F istration Form.doc Revised 04/27/2012
M M !JB, H
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.mianiibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerkamiamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME Michael J. Marrero
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
appealed to the Mia ' Dade County Commission on Ethics and Public Trust.
Signature: ate:
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EXHIBIT"B"
67K7 COLLINS D VELOPKENT
CORPORATION.a Florida eorporatinn
Madison State USA Haldings Cnrpnration.it
Florida corporation 100%Owner
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MADISON USA HOLDINGS STATE USA HOLDINGS,1AMITEU,
LIMITED.uti Ontario Carporatian an Ontario Corpar Lion
5vip owncr 1014;Owae.r
Miguel Sitrger,Cltairtttt"I Barry Z,ngdattski.Chairnum
369 Rinurock Road 3700 Durfarin Sirerm,Unit 34
Tomato,Ontario M3J.402 Ttimnto,Omprio M6B 473
COUNTRY OF CANADA 1
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PROVIYC'E 01-O,N UARIt) )
The roregoIng imartiltiel t w;Is ocknowledgcd h-fore me this Lam'(by 4)l'Jime,2D13.by;.`iiguel Singer.
as President of 6747 Collin.,Devaloprt;erit Curpun.tion.u Florida corporation,on beltnir nt-mid tmaity, 11e is
pl-mionully known to nx or produwcd nS id0atlfica, Lyrt,�
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NoUry Public,Country of C':�oi�idil i
h[�?ov»rni5sit n' xpit�s: Cumminsion No.
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