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Donald Washburn - CBMIA Restaurant Miami, LLC (04.01/4-- mi Am BEAci.i 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) (MI) The Audio Bug 3800 Hillcrest Drive, Unit 102, Hollywood FL 33021-7937 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 954-983-2788 954-983-2789 audiobual(araol.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: Leonardo B. De Paula Pessoa, MGR NAME OF PRINCIPAL/CLIENT: CBMIA Restaurant Miami, LLC— 1001 Brickell Bay Drive, Ste. 2406 Miami FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) leo(a�cocobambu.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: Leonardo B. De Paula Pessoa, MGR • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIR CTLY,A 5%OR MORE OWNERSHIP INTEREST IN'SUCH-GORPORATION, PARTNFRSHIP()R TRUST. Seg- 44 e-h w „ II.SPECIFIC LOBBY ISSUE: c;• °0 r _ Development Approvals and Permitting Issues, including, but not limited to Historic Preservation Rerriew_Board,' 'Planning Board, Board of Adjustment, Land Use Development Committee, and City Commission, if necessary, relating°to the'property located at 955 Alton Road, Miami Beach, FL. 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, Building, Public Works and Fire Department None X Staff PB, DRB, HPB, BOA, City Commission, and Land Use None X Development Committee, as necessary Pursuant to City Code Section 2-482(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(g)Any Financial, Familial or Professional Relationship None None None '' IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required): $ .q/00 0 'C.11 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $ ,5/ 67 t.42"es./ (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.eauipment 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 Agreement with the City or application fig 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 X o: 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 CO P NSATION RECEIVED. IN THE CITY OF MIAMI BEACH MB THE PRECEDING CALENDAR YEAR. A STATEMEN S ALL BE Fl D EV .N IF THERE HAVE BEEN NO EXPENDITURES OR • II' ► _: •'► I ■ ■ ' I : ► e ' ■ ell /VV/V ). e , e / Signature of Lobbyist I do solemnly swear that all of e 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 r-quirements Signature of Lobbyist: ,&_ .A,_i_. _ f 7 "d /2 Signature of Principal/Client: / - __ ,,\16.1 111.. . • M0:i VI. LOBBYIST IDENTIFICATION: �''+`5 ° ' '''± �s ;�, �.. �, PRINCIPAL IDENTIFICATION: _T`_._ �: Produced ID '°,- Produced ID SZ°4 ' 47 Form of Identification V _ Form of Identification E o Personally known(Lobbyist) i = _, T Personally known(Principal) 3 2 °*+ , .n -4 p a• VII. SIGNATURE AND STAMP OF NOTARY: v - N m H N T f T 5 7, State of Florida,County of Miami-Dade T 3 A 2 State of Florida, County of Miami-Dade 0 o Z O y O y. Sworn to and subscribe. •- ire me worn d subscribed e me "' T CT -Ti T � � N O This ?C day of . , , ,2813 o N ° This d. •f ,2993-�- N . N o -a: , D y r W k,....4//e7* 0 Signature of P blic N.141 - tate of Florida Signature of 'ub is -State of Florida Notarization of Lobby's 's signature Notarization of Principal's signature TO BE COMPL, D CITY CLERK' S •4 ON ,p ' • / // / Lobbyist Registration Form received and verified by.. .: r • 0 ■ I F:\CLE istration Form.doc Revised 04/27/2012 I M1AMBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Rafael E.Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Donald Washburn 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 469-,appealed to Miami-Dade County Commission on Ethics and Public Trust. )„ ,,,j c l Signature Date CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1.CORPORATION If the property which is the subject of the application is owned or leased by a CORPORATION, Ilst ALL of the stockholders, and the percentage of stock owned by.each. Where the stockholders consist of another corporation(s), trustee(s), partnership(s)or other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having:the ultimate ownership interest in the entity,* CB:MIA Restaurant,.LIZ 1001 Brickell.Bau Drive, Ste..2406,Miami,Florida 33131 CORPORATION NAME and.ADDRESS NAME,ADDRESS,AND OFFICE %OF STOCK Refer tb Exhibit B Hibiscus Alton,;Inc. 1228 Alton Road Miami Beach,.FL 33139 CORPORATION NAME and ADDRESS NAME,ADDRESS,AND OFFICE %OF STOCK James.ed Lidia Resnick .. 33 90 1228 Alton Road Miami Beach,'FL 331.39 SARP Resnick Family Trust 33%. 1228 Alton Road Miami Beach, FL 33139 LR Spousal Access Trust 33% 1228 Alton Road Miami Beach,FL 33139 IF THERE ARE ADDITIONAL CORPORATIONS; LIST OTHERS,INCLUDING'CORP. NAME(S)AND EACH INDIVIDUAL'S NAME ADDRESS, OFFICE AND PERCENTAGE OFSTOCK ON SEPARATE-PAGE NOTE Notarized signature required on page 8 6 CITY OF MIAMI. BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 2.TRUSTEE If the property which is the subject of the application is owned or leased by a TRUSTEE, list the beneficiaries of the trust and the percentage of interest held by each. Where the beneficiary/beneficiaries consist of corporations(s), another trust(s),partnership(s)or other similar entity,further disclosure shall be required which discloses the identity of the individuals)(natural persons)having the ultimate ownership interest In the entity:* SARP Resnick Family Trust TRUST NAME NAME,ADDRESS,AND OFFICE %OF STOCK James Resnick,Beneficiary 50% 1228 Alton Road Miami Beach, FL 331139 Lionel Resnick,.Berieficiarq 50% 1228 Alton Road Miami Beach,FL 33139 LR Spousal Access Trust TRUST NAME NAME,ADDRESS,AND OFFICE %OF STOCK Fern Resnick{Beneficianj 25% 1228 Alton Road Miami Beach,FL 33139 Elisabeth Resnick,Beneficiant 25% 1228 Alton Road Miami Beach,FL 33139 Alexis Resnick,Beneficiary 25% 1228 Alton Road Miami Beach,FL 33139 Adam Resnick,Beneficiary 25% 1228 Alton Road Miami Beach,FL 33139 I PARTNERSHIP/LIMITED PARTNERSHIP If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHIP, list the principals of the partnership, Including general and limited partners. Where the partner(s) consist of another partnership(s), corporation(s),trust(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having the ultimate ownership-interest inthe entity,* NOT APPLICABLE PARTNERSHIP/LIMITED PARTNERSHIP NAME,ADDRESS,AND OFFICE %OF STOCK NOTE:Notarized signature required on page 8 7 Exhibit B Disclosures CBMIA Restaurant, LLC Coco Bambu Investments, LLC 34% 1001 Brickell Bay Drive, Ste. 2406 Miami, FL 33131 Coco Bambu Holdings, LLC 27% 1001 Brickell Bay Drive, Ste. 2406 Miami, FL 33131 FLCB Investments, LLC 12% 1001 Brickell Bay Drive, Ste. 2406 Miami, FL 33131 LPCB Investments, LLC 12% 1001 Brickell Bay Drive, Ste. 2406 Miami, FL 33131 XXCB Investments, LLC 12% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Ronaldo Parente 3% 11200 SW 8th Street Modesto A. Maidique, RB 339B Miami,FL 33199 Coco Bambu Investments, LLC CB Holdings Oversees, Ltd. 100% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 CB Holdings Oversees, Ltd. CBTK Comercio de Alimentos Partners 70.6% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Rafael Alves de Almendra Freitas 2.1% Av. Antonio Joaquim de Moura Andrade,737 Sao Paulo -SP Brazil, 04507-000 Jany Alves Soares Almendra Freitas 1.8% Av. Antonio Joaquim de Moura Andrade,737 Sao Paulo -SP Brazil, 04507-000 Daniel Soares Alves de Brito 21 Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo - SP Brazil, 04507-000 Joao Alberto Ribeiro Pinheiro 2.9% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Alvaro Meireles Jorge de Sousa 2.9% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Igor Fernandes Bezerra de Franca 2.9% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Bruno Lopes Marques 2.9% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Andre Camara Studart Fonseca 2.9% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Felipe Russo Barreira 4.4% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil,04507-000 Ticiana Russo Barreira Parente 1.5% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Marconi Nunes Santana 2.9% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 CBJK Comercio De Alimentos Afranio Barreira Filho 31 Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Eugenio Veras Vieira 11 Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Idezio Braga Rolim, Jr. 11 Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Arthur Souza de Moraes 12% Av. Antonio Joaquim de Moura Andrade,737 Sao Paulo -SP Brazil, 04507-000 Hegel Barreira Martinz 3% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Eilson Oliveira Studard Fonseca Filho 3% Av. Antonio joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Daniell Studart Fonseca Chehab 3% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Andre Rodrigues Parente 2% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Edmar Ronald Frota Aguiar 12% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Leonardo Correa Barros 12% Av. Antonio Toaquim de Moura Andrade, 737 Sao Paulo -SP Brazil, 04507-000 Coco Bambu Holdings,LLC CB Enterprise Holdings, Ltd. 100% CB Enterprise Holdings Afranio Barreira Filho 100% Av. Antonio Joaquim de Moura Andrade, 737 Sao Paulo -SP Brazil,04507-000 FLCB Investments, LLC Felipe Luna 100% 1001 BrickeIl Bay Drive, Ste. 2406 Miami, FL 33131 LPCB Investments, LLC Leonardo Pessoa 100% 1001 Brickell Bay Drive, Ste. 2406 Miami, FL 33131 1, • ' ' ' ----------,.--..--.•;-:5---_--,,,,,y,,---_,,,,::::,_.--•-,:...-----,--,-t-1-1-1- --'7'1',:''---1:71. .1-.• •_- - •1--.,.-;-,1 • - . - -- _ .... _ - •-- ',N.- -- • .: ---_ _ _. 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"• •-' ,,c.."1 0:- --\._ '-:-.. : 2 -,-----:- ° - .:- - 0 2- • D - - .--,4:\ --- •- - -'-c4:" ‘L---`° :-.:- - - - . _ . --.-- to : •- _ E - i , -.:-.-11.A ..,- , ,1' - - -- us ---• - -‘.--- . - --•,=-:-1 - • • -C 3 "1 1-- 1:: - - --: 0 .,7'. ,,f -. st,y:7-7N> z 1-. .. .-: •--1 c : • . : - .- -. .0' te- •-.$,, -. 17:77.:•1 •":_. —.':- 44.:'•--- t.'---: ...... U.' ., I- -CO'--. , 0 til • ' -":1'"." . :_,CO -'j,-• -.- C-...-.--1---,,c, J..7 •• ' —4; 0 ---...--. - • --Q3 ' -_> --;:-E! ' , -* •'--: -•:.- E ' -=''1 87' 71.,. 1:_'.'.';.zi• 2..-0 '-.7:-- ---:_Ti• 13 -. i; • '' '-.-__:;.7 i--,..--.... .--.:-.8--,_-.-ro- ---.--:.----4 • U) C- " -• - - 0 •• -• w'--. ---•• - --,„- --- .- --' -- . 1 1 - ' ' . • . -'.. fl Prieto, Silvia From: Betty Llerena <bllerena @brzoninglaw.com> Sent: Thursday, December 11, 2014 3:21 PM To: Prieto, Silvia Subject: RE: Disclosures for CBMIA, Restaurant Miami, LLC Don Washburn compensation =$5,000.00 total I am waiting on a reply from Jose Gomez's office. I was able to reach him about the annual fee and he is working on getting that paid. Betty Llerena 305-377-6224 office BERCoW RADaL.L&FERNANDEZ r LAt'I)Unit.A.iry h MVl LAW The information contained in this electronic message is privileged and confidential and is intended only for the use of the individual named above and others who have been specifically authorized to receive such. If the recipient is not the intended recipient,you are hereby notified that any dissemination,distribution or duplication of the communication is strictly prohibited. If you have received this communication in error,or if any problems occur with transmission,please immediately notify us by telephone(305)374-5300. From: Prieto, Silvia [mailto:SilviaPrieto @miamibeachfl.gov] Sent:Thursday, December 11, 2014 2:29 PM To: Betty Llerena Subject: RE: Disclosures for CBMIA, Restaurant Miami, LLC Muchisimas gracias a ti. s Silvia Prieto,Administrative Aide I CITY CLERK'S OFFICE 1700 Convention Center Drive,Miami Beach,FL 33139 Phone:305-673-7000 ext.6269/ Fax: 305-673-7254 www.m iam ibeachfl.gov We are committed to providing excellent public service and safety to all who live, work and play in our vibrant,tropical,historic community. From: Betty Llerena [mailto:bllerena(a brzoninglaw.com] Sent: Thursday, December 11, 2014 2:28 PM To: Prieto, Silvia Subject: Disclosures for CBMIA, Restaurant Miami, LLC Mil Gracias! 1 BETTY LLERENA ASSISTANT TO BEN FERNANDEZ, MONIKA ENTIN&GIANELI MESTRE Bercow Radell & Fernandez, P.A. 200 South Biscayne Boulevard,Suite 850 Miami, FL 33131 305.377.6224 I Office 305.377.6222 I Fax bllerena @brzoninglaw.com www:brzoniTi4 Iaw:com The information contained in this electronic message is privileged and confidential and is intended only for the use of the individual named above and others who have been specifically authorized to receive it. If the recipient is not the intended recipient,you are hereby notified that any dissemination, distribution or duplication of the communication is strictly prohibited. If you have received this communication in error, or if any problems occur with transmission, please immediately notify us by telephone(305) 374-5300. 2