Graham C. Penn - TB Purdy Restaurant, LLC t757 Ave
p- AI A \ B E AC H
City of Miami Beach Office of the City Clerks
1700 Convention Center Drive, Miami Beach, FL,331.391 �i s
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to'ericourage therpassage, 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.
Penn Graham C.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell 8a Fernandez, PLLC, 200 South Biscayne Boulevard, Suite 850, Miami, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-374-5300 305-377-6222 apennOBRZoninaLaw.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:
Jeff McInnis
NAME OF PRINCIPAUCLIENT:
TB Purdy Restaurant, LLC 200 East 3" Street New York New York 10009
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 746-1105
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: eiz'
• 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: ---�
Development Approvals ansi PerrRitting Jss.es; including, but not limited to the Historic Preservation Board, Design Review
oard,Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or
Committees, if necessary l u t i n g t o the propertra located a t-1 7 8 7 Purdu Avenue. Mia nr each Florida.
Issue to be lobbied(Describe in detail): --- ��"
lll. 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
Staff for the Planning Department, Building Department, None. X
Public Works and City administration, PB, HPB, BOA, None. X
City Commission, and Mayor as necessary 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 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_
1Vone,
10)
C:\Users\clerhatt\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registr-ion
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)$475.00 per hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $475.00 per hour
(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.XIYo: L• • . • 1 1 • Si • - - 1 • • 1 ••1 • • • • • .•.. .. "•11 - 1 • - . . • •,1 • :_ - 1 • •1- 1••1 •
award for aoods.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 XNo: • • • • / 1 • • 1 •- 1 1 • . • • " . "• 1 • . 1 . - •• -I • ti -1 . . 1 1 - -4 • • • . . • 1 •
chance of zonina map desianation or change to the City's Future Land Use Man?
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 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
• !
• ► • : : ►_ ► I _ •l/ ► = • ► RECEIVED. IN THE CLTY OF MIAMI BEAM{
FOR r ► •► r _: ►� ►_�:�. _ BE FILED ► IF THERE HAVE BEEN NQ.
EXPENDITURES OR •a ► _ • ► . : ► : • • : .u : • m
Air
Signs.. re of Lobbyist
I do solemnly swear that all of the ore!sins_,- a e tru- -nd correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Be: ., �- : • all r-sorting requirements.
Signature of Lobbyist:
Signature of Principal/Client: ( 1
VI. LOBBYIST IDENTIFICATIO PRINCIPAL IDENTIFICATION:
e,4%
_Produced ID vim° Produced ID )rPV-C( (.t .cc.
Form of Identification - - - - -
v YONGYIHE
Notary ublic,State of New York 1.
_Personally known(Lobbyist) m hers%- . Princtp 02HE6332301
g y 3& —.71-",!"-T;' Qualified in New York County
VII. SIGNATURE AND STAMP OF NOTARY:
N�� � 4 ".--- _Comm_�i;�ian ExpiresOctober26,24�
State of rida, ' ounty of Miami-Dade s. State of Florida, County of Miami-Dade
Swor s.•.cribed before me a Sworn and subscribed before me
This day of akl016e/- , 2015 it This T day of pe C , 2015
Signatt r-'of Public Notary—State of Florida Signature of Public tary—State of Florida
Notarization of j,gbbyist's signature Notarization of Pri cipal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ No Amount Paid$ '$-(9.(9 0 MCR# q 0% 7-7-7 Date Paid ) /1 S/I S
Lobbyist Registration Form received and verified by: JAS-35--N S U a r
* `
MIAMI BEACH
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: Graham Penn
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
automatic suspended from lobbying until all fines are paid, unless the fine has been
appe to e Miami-Dade County Commission on Ethics and Public Trust.
Signature: Date:
C\Users\clerhatRA PP Data\LocalWlicrosoft Windows\Tem ora rY Internet Files\Content.Outlook\83LGQDDH\Lobb ist Registration
Formrevised 5-30-2012.doc
SUPPLEMENTARY DISCLOSURE OF INTEREST
Interests in TB Purdy Restaurant, LLC
Percentage of Interest
TB Holdings, LLC 100%
160 Greentree Drive, Suite 101
Dover, DE 19904
Interests in TB Holdings, LLC
Percentage of Interest
Janine Booth 50%
160 Greentree Drive, Suite 101
Dover, DE
19904
Jeff Mclnniss 50%
160 Greentree Drive, Suite 101
Dover, DE 19904
Interests in Purdy Partners 1787, LLC
Percentage of Interest
Purdy Partners 1787 SRC, LLC 50%
230 Fifth Street
Miami Beach, FL 33139
Purdy Partners 1787 PL, LL C 50%
1425 North View Dr.
Miami Beach, FL 33139
Purdy Partners 1787 SRC, LLC
Percentage of Interest
Scott Robins 100%
230 Fifth Street
Miami Beach, FL 33139
r fS 6 'r�-} ;s .F:.L 5 001. 1 ?
Vinci.00
Miscellaneous_Cash Receipt
CI r OF MIAMI BEACH
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❑ Cash 0 Credit Card Check#
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Account Humber: ,
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