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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.
Juul-Hansen. Thomas
NAME OF LOBBYIST: (Last) (First) (M.1)
40 Worth.Street, Suite 814 New York New York 10013
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(212)929-7109
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
1. LOBBYIST RETAINED BY:
Jason Halpern
NAME OF PRiNCIPAUCLIENT:
JHPSB Collins Ventures, LLC 184 Kent.Avenue,C706 Brooklyn NY 11249
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(212)687-3444
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,A5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
i.SPECIFIC LOBBY ISSUE:
DevelonmenLBoard Approvals for 3Q2/310J32Q03Q Collins Avenue, Miami Beach, FL
Issue to be lobbied(Describe In detail):
111.
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 Staff,PB, HPB,BOA,DRB,Commission None x
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 pes'bnnel who is
sought to be lobbied as identified on the lobbyist registration form filed. y
•
--� r
Sec 2-482(g)Any Financial,.Familial or Professional Relationship
NONE
•C:\Users\clerhatflAppDatalLocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$ 1-0z, ----"---
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 XNo: • •t., i 1! 1..1 . • :.:1 • .1•1• 1• . • . ••.., ..! .11:1 • i. •1 . • • ?:1! 1!
award for goods.e•uipment 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 lobbvina on-a oendlna aoolicati.on for a Development Aareement withthe City or application for
chanae of zonina meo desianatlon or chance to the City's Future Land Use Mao?
I
3) Pursuant to Miami Beach City Code Section 2-482(h)Any i
City ( ) ny 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. . ! -! : 1 1} 1• ! -! !I. • !! s. •1 •_ 1 ■ 1• • •11• .1 . 1.
N-11 1
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR.EACH LOBBYISLSjiALI—S L8MIT TO THE CITY CLERKA SIGNED STATEM ■ UNDER
OATH. LISTING LOBBYING EXPENDITVRES. AS NELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEAM{
Es2a THE PRECEDING CALENDAR YEAR. A_ ST' = „. I A .� .: • . = .
NDIE
EXPETUR- S OR COMPENSATION DURING THE REPORTING PERIOp,
,/____A
Signature of Lobbyist
ir
I do solemnly swear that all of the foregoing fac s are true and correct an d that I hay read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach•' Code :n• all re•orti • -qui ents.
1111111ray_—
Signature of Lobbyist: i___.,
Signature of Principal/Client:
if ,
VI. LOBBYIST IDENTIFICAT a N: PRINCIPAL IDENTIFICATION:
roduced ID 5W� 7t�3 &�-ls
Produced ID
Form of Identification Form of Identification t CV
!:. f:!"
®Personally known(Lobbyist) /Personally known(Principal) �Ny r�_
VII. SIGNATURE AND STAMP OF NOTARY: O = �a'
Nevyorlc SW-Polk- F.
State of Florida,County of Miami-Dade State of Eleeda,County ofMefni-9ade '' 0
r Public,State of Sworn acid subscribed before me i ®£I
Sworn to and subscribed before me fViitar�i F`ub+Ec,Stflte gf New York
• This r36 day of ,.201Willfied In QUEENS COUNTY This 3r4 day of SP.pieiab.e' ,2014. g
'- REC::;NO.01 HA6166358
JilAuref My Commission Expires:05/21/2015 Iii 1 Sign: ure of Public 7ary tate of Florfdp:_ Signa re of Public of ry State of Florida
Notarization of Lobbyist' signature --. '.`., Notarization,of Principal's,signature p
TO BE • • PLET_.t :Y Ty T F 0. Y %1 U
Annual Registration fee: [ I Yes[ 1 No- Amount Paid$ G'' MCR# MEW i I Date p,i jff "P
Lobbyist Registration Form received andvenfied by /1P .' ...: %'
• t
C:1 Users1clerhatllAppDatalLocallMicrosofttWindows\Temporary Internet Files\Content.Outlook183LGQDDHILobbyist Registration
Formrevised 5-30-2012.doc
I F:1CLE istration Form.cloc Revised 04/27/2012 I
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139, www.miamibcacltfl.gpv
CITY CLERK Office
Rafael E.Granado,City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 ,Fax:305.673.7254
LOBBYIST NAME: Thomas Juul-Hansen
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 I-Dad County Commission on Ethics and Public Trust.
Signature: Date:
S€€
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Camm, Patrick
From: Diana Ramos <dramos @brzoninglaw.com>
Sent: Friday, May 29, 2015 4:19 PM
To: Camm, Patrick
Subject: FW: Lobbyist Registration Form
Attachments: SKMBT_C36015052914410.pdf;SKMBT_75015052915490.pdf
Name of Chief Officer, Partner, or Beneficiary:Jason Halpern
Disclosures: See attached.
Lobbyist disclosure and principals disclosure: $400.00 each
Thanks,
VCARD
DIANA RAMOS
ASSISTANT TO GRAHAM PENN, MICKEY MARRERO
&CARLI KOSHAL
BERCOW RADELL& FERNANDEZ, P.A.
200 South Biscayne Boulevard, Suite 850
Miami, Florida 33131
(305) 377 6239 OFFICE
(305) 377 6222 FAX
DRAMOS @BRZONINGLAW.COM
BERCOW RADELL& ERNAN DEZ
ZONING. LAND USE ANO ENVIRONMENTAL.LAW
WWW.BRZONINGLAW.COM
From: Diana Ramos
Sent: Friday, May 29, 2015 3:44 PM
To: 'patrickcamm @miamibeachfl.gov'
Subject: Lobbyist Registration Form
Hello Patrick,
Thank you for your time. Please see the attached.
Have a nice weekend.
1
SUPPLEMENTARY DISCLOSURE OF INTEREST
Interests in JHPSB Collins Ventures, LLC
Percentage of Interest
295 LNP, LLC 15/8%
184 Kent Avenue, C706
Brooklyn NY 11249
PSB Collins, LLC 84.22%
555 Madison Avenue, Suite 508
New York NY 10022
Interests in 295 LNP, LLC
Percentage of Interest
The Jason Halpern Life Insurance Trust 90%
184 Kent Avenue, C706
Brooklyn NY 11249
Jason Halpern 10%
184 Kent Avenue, C706
Brooklyn NY 11249
Interests in The Jason Halpern Life Insurance Trust
Percentage of Interest
Jason Halpern 100%
184 Kent Avenue, C706
Brooklyn NY 11249
Interests in PSB Collins, LLC
Percentage of Interest
Dhruv Piplani 100%
555 Madison Avenue, Suite 508
New York NY 10022