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Roman Jones - Mokai Lounge, LLC „d MIA/01 Z� C City of Miami Beach Office of the City Clerk CJ a\ 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. Jones, Roman NAME OF LOBBYIST: (Last) (First) (M.1) 690 Lincoln Road,Suite 201, Miami Beach, Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786)507-3448 roman @theopiumgroup.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: Mokai Lounge,LLC NAME OF PRINCIPAUCLIENT: Mokai Lounge, LLC, 690 Lincoln Road,Suite 201, Miami Beach, Florida 33139 _ bUSINE-SS NAME AND ADUKESS (Number and Street) (City) (State) (Lip Code) (786)507-3448 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: Roman Jones, Manager • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached. II.SPECIFIC LOBBY ISSUE: Progress Report under Planning Board File No. 1764 for Conditional Use Permit covering 235 and 219 23rd Street. Issue to be lobbied(Describe in detail): III.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 relationship. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied Planning Board X Planning Director and Staff X Pursuant to City Code Section 2482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed. Sec 2-482 Any Financial,Familial or Professional Relationship --Ini -1 !:, C VII I: 05 :01 s11V 61 �d� EIOl C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration tj Formrevised 5-30-2012.doc ?� IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) no additional compensation for lobbying B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): no additional compensation for lobbying (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 IM/0. 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes/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 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 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 COMP SATION RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE HIA ED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. nature of Lob yi t I do solemnly swear that all of the fore i g facts are tr and correct an that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach ode and all re rting requirem nts. Signature of Lobbyist: 4 Signature of Principal/Client: VI. LOBBYIST IDENTIFICATI 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 Mi i- d State of Florida, County of Miami-Dade Sworn and subs ib d bef Swor and subsc e e Notary Public State of Florida This da of o day 0 Sandra Careaga Ne! ry Public State of Florida My Commission EE144267 ;p Sandra Careaga s 12/13/2015 ° Commission EE144267 Si a of blic Notary— Signature of Public N ary— at ridgkpires 12/13/2015 Notarization of Lobbyist's signature Notarization of Principal's TO BE COMPLET D BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes( ]No Amount Paid$ MCR# ?2.7 DatoPald Lobbyist Registration Form received and verified by: C:\Users\clerhatMppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\831 G DDH\Lobbyist Registration Formrevised 5-30-2012.doc F:\CLEI tistratian Form.doc Revised 04/27/2012 MIAMIBEACH City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1 ,Fax:305.673.7254 LOBBYIST NAME: l�d�)`� �1 � � _S 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 susp nded from lobbying until all fines are paid, unless the fine has been appealed to the MI i-Dade County Commission on Ethics and Public Trust. k- D Nk e40 �3 Signat re: Date: C:\Users\clerhatlWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc DISCLOSURE OF INTEREST MOKAI LOUNGE,LLC Name and Address %of'Ownership Mokai Lounge Manager,LLC 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Roman Jones Companies,Inc. 55.118% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Roman Jones 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Mokai Investors,LLC 11.811 % 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Mitchell Rubinson 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Mokai 23,LLC 11.811 % 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Francis Milon 50% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Erics Milon 50% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 JL Club Holdings,LLC 11.811 % 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Justin Levine 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Haute Investments,Inc. 3.543% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Jaime Rubinson 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Nomade Investments,Inc. 5.906% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139 Hassan Benjelloun 100% 690 Lincoln Road,Suite 201 Miami Beach,Florida 33139