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Jose L. Gomez - Texas Taco Factory Express, Inc. w LI pc!_ l( 15''`'L 31re � City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM J 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) 1305)559-1250 (305)551-1740 ianabeilinsonarchitectspa.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: Texas Taco Factoru Express. Inc. NAME OF PRINCIPAUCLIENT: Texas Taco Factory Express, Inc., 1608 Alton Road, Miami Beach FL 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-498-6318 neallminabellsouth.net 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:Leland Neal • 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 and Permitting Issues;including, but not limited to the Historic Preservation Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or Committees, if necessary. relatina to the property located at 409-411 15th Street. Miami Beach.Florida! Issue to be lobbied(Describe in detail): Ill. 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. None. C:1Users\clerhatlWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration . Formrevised 5-30-2012.doc . • 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: Jose L. Gomez 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 Mi. mi-Dade County Commission on Ethics and Public Trust. 5\lO2O1 to Sig -ture: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc 10 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION,PARTNERSHIP,OR LIMITED LIABILITY COMPANY If the property that is the subject of the application is owned or leased by a corporation, partnership, or limited liability company, list ALL of the owners, shareholders, partners, managers, and/or members, and the percentage of ownership held by each. If the owners consist of one or more corporations, partnerships, trusts, partnerships, or other corporate entities, the applicant shall further disclose the identity the individual(s) (natural persons) having the ultimate ownership interest in the entity.* Texas Taco Factorrs Express, Inc. NAME OF CORPORATE ENTITY NAME AND ADDRESS %OF OWNERSHIP Leland Neal 27% 8507 Franio Road, Miami, FL 33189 James Ross 27% 14370 SW 98 Terrace, Miami, FL 33186 Javier Cervera 22% 5025 SW 62 Avenue, Miami, FL 33155 Milaaros Diaz 12% 1608 Alton Road, Mia.mi,Beach, FL 33139 Marlon Palmer 12% 1608 Alton Road, Miami Beach, FL 33139 1500 Washington, LLC NAME OF CORPORATE ENTITY NAME AND ADDRESS . . %OF OWNERSHIP Michael.Comras 50% 1261 20,11 Street, Miami Beach, FL 33139 JTC 2006 Trust FBO Michael Comras 16.67% 1261 20,1 Street, Miami Beach, FL 33139 JTC 2006 Trust FBO Richard Comras 16.67% 401 E. Rivo Alto Dr., Miami Beach, FL 33139 JTC 2006 Trust FBO Ashlers&Bryan Comras 16.66% 246 E. 4'h ST,Apt. 3, New York, NY 10009 IF THERE ARE ADDITIONAL CORPORATE OWNERS, LIST ALL SUCH OWNERS, INCLUNG CORPORATE NAMES AND THE NAME,ADDRESS,AND PERCENTAGE OF OWNERSHIP OF EACH ADDITIONAL OWNER, ON A SEPARATE PAGE. NOTE:Notarized signature required on page 9 FILE NO. • Miscellaneous Cash Receipt cline OF MIAMI BEACH _ . • . - 1 0 CT 1.0 , ..• • • , _ _•,,..,.. ,) v 4.2- , . . .,. .. i,o s 0- 04) g: . El Cash 0 Credit,Card Check# i 3-,-) - -/:,-,_:, ,, ,i • . i ,... A ..... L i.,... • (....7...-,,),,c g'' 1 -4.-c...ArQ.,, /91,111. ei C-14.1.el mRStretil ed f ''''\° ' ' '11C city of IN ia V 0 SC — .11 , '-.,&t Miscell eoukctirass2rC f 0 - ig t. ,A 5 , 379 A, . 35 131.. _ 000065- 066 Jenel F...g5trui2.0 1 6 5:3571,;Ati ..z., /31 Iv.d .5yc .5-.../ /4 IA. If MCR,OPEN FC)r '''/ - t '. • . '.. . ' . ,t. : - Payment Amount: ....)s - ),Q5S.PpeS - -. - - • - '' ; ...i. 1 , MCR409910 (THIS INFORMATION MUST BE COMPLETED) ' Office of Finance Director By . .-- •,- . , - , .. - • - , .. 0 0.. 30,-). 3 f.,;---,.. ,I-;(,) ..f,C):',. .0 Or - C)/if' OC)OO - 361!' t/Litt s — ‘-•-) ' ''. Account Number , -., • 1 l'i,-'-`i.AW,";_,.:,', , \ ..- . .. .,,e-i6. .. D- t. 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