2024 Lobbyist Registration Form - Five Below Conditional Use Permit (Patrick Buckley, Five Below Inc.) DocuSiqn EnvelopelD:45891535-E0064B63-BDCEFBACF5209145
-+�-i;EIVED
� � �� 25 2024
� Offioe of the Clty Clerk
17�0 Convention Center Drive —� I f � '�- �'I��iJll rrFACH
Miaml Beach, FL 33139 �� ,LEr;K
305.6737411
LOBBVIST REGISTRATION FORM
Lobbyist means all persons employetl or retainetl, whether paid or nol by a principal who seeks to encourage the passage, tlefeat or
modifcation of any ordinance, resoNlion, action or tlecision of any commissioner any action, decisioq recommentlation of the Ciry
Manager or any CiTy board or committee',or any action, tlecision or recommentlation of any City personnel during ihe time periotl of the
entire tlecision-making process on such action, decision or recommendation thal foreseeably will be heard or reviewed by �he City
Commission, or a Ciry boartl or committee. The term specifcally indutles ihe principal as well as any employee engaged in lobbying
activities. The term 'Lobbyist` has specifc exclusions. Please refer to Ciry Code Chapter 2, Articie VII, Division 3. entiHed "Lobbyists."
for atltlitional in(ormation.
Instructions: Please complete all sections o(this fortn and submit Ihe completed form, wilh lhe applicable fee. to the Office o(ihe City
Clerk. If you need more space to complele an answer, use a separale sheet(s) of paper. If you have nothing to report in a pa�icular
section, you must write "none" or "nla" in that sectioa Any change ro any information originalty fled, or any additional City
Commissioner or personnel who are also sought to be lobbied shall require lhal the lobbyist fle an amentlment to lhe registration form.
The lobbyist has a mntinuing duty to supply in(orma[ion and amentl the forms fletl lhmughout the period ihal the lobbying ocwrs.
Separate registration fortns shall be required for each principal representetl on each specifc issue.
I. LOBBYIST INFORMATION:
Vicke�s � Devon
NAME OF LOBBVIST (Lasp (Firs�) (Mitltlle Name)
Greenberg Traurig, P.A. 333 SE 2nd Avenue, 44th Floor Miami FL 33731
LOBBVIST eUSME55 NAME ANp ADDRE55 (NumEer and SVee[) (Clry) (Slate) (Zip Cotle)
305-579-0827 305-297-8750 vickersd@gtlaw.com
LOBBVISTBUSMESSTELEPHONENUMBER CELWLARTELEPHONENUMBER EMAILA�DRESS
II. PRINCIPAL INFORMATION: �
FiveBelowlnc. c�o BV�KIC�J PahiC.�
NAMEOFPRINCIPAL � (Lesq � (Flrs[) (MltltlleName)
Five Below Inc. 701 Market Street, Suite 600 Philadelphia, PA 19106
PRINCIPALBUSMESSNAMEANDAD�RESS (Numberend5Vee1) (Gry) (S�a�e) �pCode)
978-833-6945 Angela.Petralia@fivebelow.com; Elizabeth.Lanza@fivebelow.com
PRMCIPALBUSWESSTELEPHONENUMBER CELLULARTELEPHONENUMBER EMAILADDRESS
Pursuan�to Ci�y Cotle Section 2-A82(h)(1)(a)'. A pnncipal of any mrparation, partnership, ar oNer entiry who appears as a lobbyist on behalf of�ha�
en�ity,vnihout speual compensation or reimbursemen[for[he appearance,whefher direc�, indirecl, or con�ingen�,�o express support of or opposi�ion�o
an ilem shall register wltM1 Ihe qeM as requiretl by�his subsec�ion bul shall mt be requiretl to pay any regis[ation fees.
If the principal is a Corporation, Partnership or Trust, the following information MUST be provided
pursuant to City Code Section 2-062(c�:
• NAME OF CMIEF OFFICER, PARTNER, OR BENEFICIARY(if none,write N/A�: PQiYI Gk yUG��e y � ASSY� 6Ch��P
�✓�'J
• NAME OF ALL PERSONS HOLDING, DIRECTLV OR INUIRECTLV,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST(if none,write NIA�:
Publicly traded company.
Page 7 of 5
��1\ �
.�
�acuSiqn Envelope ID'.45891535-E0061B63-BDCEFBACF5209145
III. ISSUE TO BE LOBBIED:
Describe with as much detail as is practical, including but not limited to a specific description
where applicable of a pending request for proposal, invitation to bid, or public hearing number.
Conditional use approval before Planning Board.
IV. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482�a)(4�, list the City Commissioner or City personnel sought to be
lo6bied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with
said City Commissioner or City personnel from �2 months preceding such commencement of service
with the City to the present date, stating the general nature of the subjett contractual relationship.
Full Name of Individual and Contrac[ual Relationship(If yes,explain) �ES NO
Title of Person to be Lobbied
City Commissioners and Mayor X
City Manager, City Attorney X
City Boards X
All City Departments 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
appearence of an impropriety, with any current City Commissioner or City personnel who is sought to
be lo6bied as identified on the lobbyis[ registration form filed.
List any Business, Financial, Familial or Professional Rela[ionship, or other rela[ionship giving rise to an
a earance of im ro rie if none,write N/A :
N/A
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a
contingency fee is prohibited pursuant to City Code Sec. 2-485.3):
$660/hour
Page 2 of 5
DocuSign EnvelopelP.4589153SE006-4B63-BDCE-FBACF5209145
The�ollowing six(6)questions MUST be answered:
1) Pursuant�o Ciry Cotle Section 2�88.. entitletl'Prohibi�ed Campaign ConiribWions ey Lobbyisis On Procurement Issues"'.
_Ves VNo: Are o I bb ' t d b'tl f q ds t t
oentlinaawardtoruootls eau'om¢n[orsarv'cei
2) Pursuant lo City Code Section 2-090, entitled'Prohibited Campaign Contributions By Lobbyisis On Real Estate Development
Issues':
_VeS�No: Are y I bb ' d' ool' t' f D I t A t 'th th C'N I' t'
f h q t o ' p d 'q t' Cha t th C'N' F t e La d U M i
3) Pursuant to Ciry Code Secfion Y-482(h�, any person (except those exempt from Ihe definitlon of "IobbylsP' as set forth ln
Section 2-481) who only appears as a representative of a not-for-pmfit carporation or en�iry without special compensa�ion or
reimbursement for the appearance,whether tlirect or intlirect to express support of or opposition to any i�em,shall register with
the city cerk as requiretl by this sectioq but shall not be requiretl ro pay any registration fees.
_Ves_No: Ar¢ o C bTo - ft C £h 'th t ' I o f
reimburs¢ment9
4) Pursuant ro City Code Section 2<81, ihe term "lobbyist" specifically excludes the following persons Expert witnesses who
provitle only scientif4 technical or other specialized infortnation or testimony in public meetings; any person who only appears
as a representative of a neighborhootl association withou�compensation or reimbursement for the appearance,whether dired,
indirect or contingent.to express support of or opposition to any item�, and any person who only appears as a representative of
not-for-profit community basetl organization for ihe puryose o/ requesling a grant without special wmpensation or
reimbursement for Ihe appearance.
_Yes�[fJo: Are v o o 'd' I tf' tech ' I th 'al' ed ' f t' oo ' a as
reores¢ntatbe ot a ne'ahborhood ass ' C 'th t 'al com f ' b se t
reo C q oPf - ft b tl q ' C f th o i f q t 'tho t
5pecial comoensation or reimbursement7
5) Pursuant to City Code Section 2d97(1), no campaign consultant shall labby Ihe Ciry Commission for a period of 12 months
following the swearing in of any electetl official(s) for whom the campaign consultaN pmvidetl campaign consulting services
within the past elecfion cycle. See Section 2-491 for more information.
_Ves�No: Have vou orov'detl camoa'an consulfnn serv'ces lo an 'ncumben[memb r f th C'N C
wi[hin th¢oast eleclion cvcle7 If ves oleas¢I'st the'ncumbent memberls)of[h¢C'N C
_Ves�[fJo: I�es has it bean less than 72 months s'nce the electetl off'c'allsl whom "tl tl oalan
consultina services was sworn in7
6) Pursuant to City Cotle Section 2-082�a��4�a., a lobbyist who has within the past election cycle provitletl campaign consulting
services to an inwmbent member of the City Commission (which lobbying activity is not otherwise prohibitetl by Code section
2-091) shall disclose such particular service on his/her lobbyist registration form and shall orallv disclose such oartcular
service belore lobb in the CI Commission at a oublic meetino.
Ves No: Have vou orov'tled eamoa'qn ronsulfna serv'ces to an 'nwmbent m mb r f th C'N C
'th' th t I Co c I 7 If I f t th ' be t beH 1 f th C'ry C
_Ves�No: I( ves were vou orom'sed or d'tl vou rece've econom'c cons'tleroCon ' h a f a'a
consultinq sarvices?
cn,,q TO BE COMPLETED BY CITY CLERK'S STAFF ONLV
AnnaI RegkUat�ionlee�'.J[��No Amounl Paitl 5 1/�o MCR# y33��7 Date Pain �' � S—��/
LOEbylst Regislration Form receivetl antl verifletl by: � �f
F.\i,IN.1]NIi.FiiftMS\LOftHYISTF�NMS\LObbyis[kcrp5batlmFo�m0.¢v15¢tl03-11-30REG.�m 0.evisetl03/11/3020
Page 3 of 5
DocuSiqn Envelopel0'.45891535-E006-4B63-8DC6F8ACF5209145
VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBVIST SHALL SUBMIT TO THE OFFICE OF THE qTY CLERK A
SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
RECEIVED, FOR 7HE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGED 70 LOBBY A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSATIONDURING THE REPORTING PERIOD '
�1
Signature of LobbylsT. ��� . �' �� �^ Date � �Z4�z�Zy�
1
I do solemnly swear or affrm that all of the foregoing facts, statements, and disdosures in this form are ime and correct,
and Ihat I have read or am�miliar with the proqisions wntained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
Ihe Miami Beach City C,,�e+/ana� I reportin requi enib�nts.�,
Signature of LobbyisL � Y1�. �1�,�`—� �„ Date_ � � 2`f f�Z`f
oo�� rasr
Signature of Principal�. ����� ���u� � Date 12/13/2023
�ouo�eaeaerair..
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
Stateof_ \\�Y..aq Stateof Pennsylvania
vhiladelphia
Counry of: u.`a,,.;. �,c�t County of:
Swom to (or affirmed) and subscribed before me, Swom to(or affirmed)and subscribed before me,
by means of�hysical presence by means of 0 physical presence
or� online notarization, or C�J online notarization.
this��day of�,�„�20]�y by this 132�Nay of oecember 20 Z3, by
—17c.pov� V` �c�r.c,r� Pavick � auckley
NAME OF LOBBVIST NAME OF PRINCIPAL
_ProducedlD ProducedlD
FORM OF I�ENTIFICATION FORM OF IDENTIFICATION
✓Personally Known �/no_wn /
�natur�ofDla[ary FLi61�c -- Signature o o aryy ti
�Q`r�A —So�¢. Laowb ndam Mc�ane
Name of Notary, Typed, Printed or S mped Name of Notary, Typed. Printed or Stamped
(NOTARY SEAL) .�,� (NOTARY SEAL) ADAM MCLANE
;p�e, .wte, 'cs ooZ NofaryPublic-NotarySeal
-. Nmary v�_o� �Se e �:'mrica Commonwealth of Pennsylvania
� � Comms � . w o9llN Philatlelphia County
^`' MyComm.[.c�res:zr�a.1e15 Commissian Number 12982fi4
'The term "IobbyisP'specificall My Commission Ezpires 5/12I2024
Expert witnesses who provitle only scientific, technical or other specialized information or testimony in public meetings', any person who
only appears as a representative of a neighborhood association without mmpensa[ion or reimbureement for(he appearance, whether
tlirect. indirec�or contingent. to express support of or opposition to any item; and any person who only appears as a representative of
noFfor-profit communiry basetl organization for the purpose of requesting a grant without special compensation or reimbursement for
the appearance.
Page 4 of 5
DoaSign Emelope ID:65891535-E006-4B63-BOCEFBACF5209145
Ciy d Miami Beach, V00 Convemlon Cenler Drive,Mlomi Beach, Florida 33139,vm^o.miami6eochfl.go.
Office of ihe Ciy Clerk
Rakal E. Gronodo, Cily Clerk CilyClark�miomibeachfl.gov
7e1� 305.673.7411, Faz: 305.673 7254
NAME OF LOBBYIST: Devon Vickers
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION S7ATEMENT
Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or
principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement
(Statement). In addition to any other penalties that may be imposed as provided in
Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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 aker notifcation.
Any lobbyist, who fails to file the required Statement by April 30'" of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyist expenditures, as well as compensation
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediatety file a Notice of Withdrawal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I understand annual registration of all lobbyists shall be required for each 12-month period
commencing October 1 of each year, and the fee for such annual registration shall be
$500.00 pursuant Ifp Section 2-482 of the Miami Beach City Code.
� �'�, f �
�/� � � ,� �j
�/ V �✓�, �I'Y'�-�.� I —2�} — 2 oz�+
Signatu�e of Lobbyist �� Date
,`
F�cca�sn��aFoams�earis roams�000¢im aaa�+ireuo�Fo�a��a osr-�o aeam�
Page 5 of 5
Miscellaneous Cash Receipt
CITV OF MIAMI BEACH No. 433007
❑Cash ❑Credit Card 'flCheck N � � , . $ �
20
Received of � �
Address ����
For
� '
FCR DEPOSIT ONLY
JAN Z 5 2024
Office of Finance Director
(THIS INFORMA��(�5'�E�+�1����) By __
AccouM number:
Preparer: �� Dept: -� EXT. �� �_ .�
�
4
� E
. .
4
,
,