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Louis Terminello/Cafeteria SB in Mi,lml Br:,:<s7n - - ZtJiJj 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 defined in any manner in this section, 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. Terminello Louis J. NAME OF LOBBYIST: (Last) TERMINELLO & TERMINELLO, P.A. BUSINESS NAME AND ADDRESS (Number and Street) (City) 2700 S.W. 37th Avenue Miami (First) (M.I) (State) FL (Zip Code) 33133 TELEPHONE NUMBER: (305 ) I. 444-5002 LOBBYIST RETAINED BY: Cafeteria of South NAME OF PRINCIPAL/CLIENT: d/b/a Cafeteria FAX NUMBER: (305) 448-5566 EMAIL: ljt@terminello.com Beach, LTD, LLLP 546 Lincoln Road Miami Beach, FL 33139 BUSINESS NAME AND ADDRESS (305) 672-3663 TELEPHONE NUMBER: (Number and Street) (City) (State) (Zip Code) FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (cl] NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Susan Leonard, President, ALP of South Beach, Inc., Managing Member Cafeteria of South Beach LLC, Managing Member, Cafeteria of South H~ach, Ltd, IDENTIFY ALL PERSONS HOLDING, DIREOh OR INDIRECTLY;' A 5% OR MORE OWNERSHIP INTEREST IN SUCH LLLE CORPORATION, PARTN ERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Conditional Use Permit for Neighborhood Impact Establishment Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship City of Miami Beach Planning Dept. City of Miami Beach Board - 0 S"\.!)P7"..' II ~d' d ,^ r) \..... .~ / ;jOv 90 Q3/\/3'1:;\: v-'o IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOUR L Y, FLAT RATE OR OTHER): B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $12,500 flat fee $12,500.00 flat fee A) LOBBYIST DISCLOSURE: (Required) Yes No: Are vou reoresentinG a not-for-orofit corooration or entity without soecial comoensation or reimbursement. Pursuant to Ordinance No. 2004-3435. 1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5 Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited Camoaian Contributions Bv Lobbvists On Procurement Issues": Yes No: Are vou 10bbvinG on a oresent or oendinG bid for Goods. eGuioment or services. or on a oresent or oendinG award for Goods. eGuioment or service? 2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5 thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited Camoaian Contributions Bv Lobbyists On Real Estate Develooment Issues": Yes No: Are vou 10bbvinG on a oendinG aoolication for a Develooment AGreement with the City or aoolication for chanGe of zoninG mao desiGnation or chanGe to the Cit'.r's Future Land Use Mao? V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. \J ~ Signature of Lobbyist I do solemnly swear that all of the 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 requirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATIO Produced ID Produced ID Form of Identification Form of Identification Personally known (Lobbyist) Personally known (Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Frida, County of Miami-Dade Swor t nd subscribed before me 04 This day of August. 20_ Signature of Public Notary - State of Florida Notarization of Lobbyist's signature Annual Registration fee: [ ] Yes [ ] No A:O~~~~~~N;~o?7/ Jj Date Paid Ml-() L( Lobbyist Registration Form received and verified by: Revised 02/10/04 F: CL R\ALL\MARIA-M\LOBBYIST\LOBBYIST FORM 04