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Donald Washburn - Senor Frogs Miami, LLC r- • 1 a vz 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. WASHBURN DONALD NAME OF LOBBYIST: (Last) (First) (M.1) The Audio Bug, Inc. 3800 Hillcrest Drive, Unit 102, Hollywood, Florida 33021-7937 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (954)983-2788 (954)983-2789 audiobug1 @aol.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: Senor Frogs Miami, LLC NAME OF PRINCIPAL/CLIENT: Senor Frogs Miami, LLC 1000 5th Street, Suite 1311, Miami Beach, Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (407)414-2974 rana @andermail.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: Renato Alvarado Chavez, Manager IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached Exhibit"A". II.SPECIFIC LOBBY ISSUE: Conditional Use Permit for a Neighborhood Impact Establishment at 1450 Collins Avenue,Miami Beach,FL 33139;and any land use,development, zoning,design,or licensing issues relating to the subject property. 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 eneral 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 City of Miami Beach Planning Board None ` X Planning Director and his staff None X Parking Director and his staff None 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 ,- tj None L I :6 144 9 SMV X 101 QK (�8/zBlZo<Ly IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) 451000 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (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 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": ❑Yes 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 0 No: Are you representinq 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 SiqALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. a 1 Sign 'ure of Lobbyist I do solemnly swear that all of he foregoing fact e t e and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Mia i B ach Cit- de d rep rting r 'tements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICA N• PRINCIPAL IDENTIFICATION: .produced ID If Y7'NS"O" X-Produced ID K�17Z�p OI 30 Form of Identification Form of Identification ❑ Personally known(Lobbyist) ❑ Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: 31 V14, IP State of Florida,County of Miami-Dade , Arnof rida, County of Miami-Dade S k- �t Sworn to n subscribed before a � Q * .,•:aa`' ubsc ib d before me �. ? `� This day Of u►S 2014 0'1Bn°* 8a to wS�'" ,20 14 Signat is Notary—State of F Signature Ic ary—State of Florida���c * ;. Notarization of Lobbyist's signatu_ Notarization of Principal's signature & •• ° t• a TO BE COMPLETED BY CITY CLERK'S STAFF ONLY s• o Annual Registration fee: [ ]Yes[ ]No Amount Paid$___72 MCR# D Paid Lobbyist Registration Form received and verified by: a F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 1/11/2011 City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 1 Fax: 305.673.7254 LOBBYIST NAME: DONALD WASHBURN I understand that no later than February 28th of each 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. I) 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. 5 47", /Cj Signature: Date: EXHIBIT"A" DISCLOSURE OF OWNERSHIP INTERESTS SENOR FROGS MIAMI,LLC Name and Address %of Ownership Senor Frogs Miami,LLC GH10 USA,LLC 100% 1000 5th Street,Suite 1311 Miami Beach,FL 33139 GH10 USA,LLC GH9,S. De R.L. 100% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 GH9, S.De R.L. Janleah,S.A. De C.V. 30.06% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun, Quintana Roo 77533 Las De Lalo, S.A. De C.V. 11.26% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Anarpa Compagnie,S.A. De C.V. 10.53% Acanceh MZA 3 LT 3 LOC 22 PH SM 15 A Quintana Roo 77500 Holding Villarox, S.A. De C.V. 10.53% Avenida Bonampak Manzana 1 Lote 3 Local 202 Super Manzana 3, Cancun,Quintana Roo 77500 Son Del Primo,S.A. De C.V. 6.08% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello, Cancun, Quintana Roo 77533 Akatan,S.A. De C.V. 2.96% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Grupo Holding GTZ, S.De R.L. De C.V. 2.42% Bonampak 3 Manzana 1 SM 3 Cancun Benito Juarez, Quintana Roo 77500 Ranaca, S.A. De C.V. 2.39% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun, Quintana Roo 77533 EXHIBIT"A" DISCLOSURE OF OWNERSHIP INTERESTS SENOR FROGS MIAMI,LLC Page 2of4 Taniseb,S. De R.L. De C.V. 0.87% AV Acanceh Lote 3 Manzana 2 Local 202 Supermanzana 11, Cancun Benito Juarez, Quintana Roo 77504 Grupo Restaurantero Shamdas, S.A. De C.V. 17.20% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Cuatro Por Ciento, S.A. De C.V. 5.70% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Janleah,S.A.De C.V. David Leonardo Krouham Litchi 99% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Jorge Eduardo Lizarraga Flores 1% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun, Quintana Roo 77533 Las De Lalo,S.A. De C.V. Eduardo Beaven Magana 99% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Alejandro Beaven Magana 1% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Anarpa Compagnie,S.A.De C.V. Adrian Gomez Oyanguren 98% Acanceh MZA 3 LT 3 LOC 22 PH SM 15 A Quintana Roo 77500 Miram Rodriguez Cardenas 2% Acanceh MZA 3 LT 3 LOC 22 PH SM 15 A Quintana Roo 77500 Holding Villarox,S.A. De C.V. Rodrigo Villanueva Aguirre 98% Avenida Bonampak Manzana 1 Lote 3 Local 202 Super Manzana 3, Cancun,Quintana Roo 77500 Ana Belen Aquino Alcalde 2% Avenida Bonampak Manzana 1 Lote 3 Local 202 Super Manzana 3, Cancun,Quintana Roo 77500 EXHIBIT"A" DISCLOSURE OF OWNERSHIP INTERESTS SENOR FROGS MIAMI,LLC Page 3 of 4 Son Del Primo,S.A. De C.V. Alejandro Schoer Diestel 99% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Norma Gabriela Graf de Shoer 1% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Akatan,S.A.De C.V. I.Tan Investments, Inc. 99% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Kristel Andrea Camino 1% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Grupo Holding GTZ, S. De R.L. De C.V. Alejandro Gutierrez Robles 99% Bonampak 3 Manzana 1 SM 3 Cancun Benito Juarez, Quintana Roo 77500 Daniel Alejandro Gutierrez Romero 1% Bonampak 3 Manzana 1 SM 3 Cancun Benito Juarez,Quintana Roo 77500 Ranaca,S.A.De C.V. Janleah,S.A.De C.V. 50% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Akatan,S.A. De C.V. 50% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Taniseb,S.De R.L. De C.V. Marion Angelika Speck Hever 99% AV Acanceh Lote 3 Manzana 2 Local 202 Supermanzana 11, Cancun Benito Juarez, Quintana Roo 77504 Fernando Dobaldo Rueda 1% AV Acanceh Lote 3 Manzana 2 Local 202 Supermanzana 11, Cancun Benito Juarez, Quintana Roo 77504 I EXHIBIT"A" DISCLOSURE OF OWNERSHIP INTERESTS SENOR FROGS MIAMI,LLC Page 4 of 4 Grugo Restaurantero Shamdas, S.A. De C.V. David Shamosh Helfon 30% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Daniel Shamosh Helfon 30% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Salomon Shamosh Helfon 30% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe Distrito Federal 01219 o , Abdo Shamosh Helfon 10% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Cuatro Por Ciento, S.A.De C.V. Simon Shamosh Charabati 50% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 Robert Shamosh Charabati 50% Avenida Vasco De Quiroga 3900 Piso 21 Torre a Lomas de Santa Fe, Distrito Federal 01219 I.Tan Investments, Inc. Jorge A.Camino 50% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello,Cancun,Quintana Roo 77533 Kristel A. Camino 50% Calle Porto Liguria 13 Manzana 15 Lote 2 SM 55 Fracc Porto Bello, Cancun, Quintana Roo 77533 Tl C� 0 o m .. m- - V aq a ❑ := c ® A d! y .. R' Z � 0 ; CA a 4 \Y D m Ns -_ { _ •• may`"+ - � f i rs p 4-4 m ti