Jose Gomez - Royal Polo Hotel LLC i f
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City of Miami Beach Office of the City Clerk d q10 � P�
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.
Gomez Jose L.
NAME OF LOBBYIST: (Last) (First) (M.I)
Beilinson Gomez Architects P.A. 8101 Biscayne Boulevard, Suite 309, Miami, FL 33138-4664
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-559-1250 x.208 305-551-1740 jg @beilinsonarchitectspa.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes address,•phone,;ore-mail address.
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
Royal Polo Hotel LLC 3785 NW 82nd Avenue, Suite 204, Miami, FL 33166
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-747-6153 305-592-3394 chris.desai @baywoodhotels.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:
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
ii SPECIFIC LOBSY_ISSUE
Requesting a 1-year extension for a variance approved (BOA File#3617, 1-11-2013)for maintaining the original room sizes
Issue to be lobbied(Describe in detail):at the Royal Polo Hotel, 2940 Collins Avenue, Miami Beach, FL 33140
.
III CITY AGENCIE, ANDIVI®UALS 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
-Zoninq Board of Adjustment X
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,familial.-or pr,ojessional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city persAj�el who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial,Familial or Professional Relationship -Q
None
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F:\CLER\$ALL\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)
$250/Hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(Required). $250/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":
O Yes Q(No: Are you lobbyinq 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 )Q No: Are you lobbyinq 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.
0 Yes )G 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 COMPENS TION RECEIVED IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT-SHALL BE FILE EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PER
Sign ture of Lobbyist
I do solemnly swear that all of the foregoing facts a tru d correct and t at I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach all re ng requirement .
Signature of Lobbyist:
Signature of Principal/Client:
Vl. LOBBYIST IDENTIF CATI PRINCIPAL IDENTIFICATION:
€ Produced ID € Produced ID
Form of Identification '-�, ,•,�^°,� Form of Identification
eueea`�
Personally known(Lobbyist) n C _ Personally known(Principa)
VII. SIGNATURE AND STAMP OF NOTARY 3 3
State of Florida,County of Miami-Dade • d, State of Florida,County of Miami-Dade
Sworn to and subscribed before me Sworn and subscri d before me
This 21st day of SU L. , 2014- o 0. day of vST ,2011
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Signature Public Notary—State of FI ida Signature of Public o Flurial, MARIA RUBIO
Notarization of Lobbyist's signature NotariKation of Princi al' e: oti Notary:Public-State of Florida
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY 13 My Comm.Expire*Jan 26,2011 olon*EE 2
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ .MCR# Id d A>isn
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Lohhvict Ranictratinn Fnrm ranahiard anrd varifiad by
F: ?orm.dac Revised 1/11/2011
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: Jose L. Gomez
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 ode County Commission on Ethics and Public Trust.
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