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Louis J. Terminello/KAAMOS, LLCm Mlr',fv11BEACH 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. TERMINELLO, LOUIS J. NAME OF LOBBYIST: (Last) (First) (M.I) 2700 S.W. 37 AVE. MIAMI, FLORIDA 33133 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-444-5002 305-448-5566 LJT@TERMINELLO.COM TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST RETAINED BY: KAAMOS, LLC NAME OF PRINCIPAUCLIENT: 650 WEST AVENUE, SUITE 1712 MIAMI BEACH, FLORIDA 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-793-4437 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: TED SNIDER • 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: CONDITIONAL USE APPROVAL FOR A NEIGHBORHOOD IMPACT ESTABLISHMENT FOR RESTAURANT AND ACCESSORY BARS AT 1650 JAMES AVENUE. issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section z-4s2(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship PLANNING BOARD NO gp :~ ~d h- ~~~ BQOZ ~~t ~ri~~ ~ ~, IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) $15,000 FLAT FEE THROUGH FIRST PUBLIC HEARING. $400 PER HOUR THEREAFTER. B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): $15,000 FLAT FEE THROUGH FIRST PUBLIC HEARING. (Required). $400 PER HOUR THEREAFTER. 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": present or pending award for goods. equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real~Estate Development Issues": application for chance of zoning map designation or chance to the Citv's Future Land Use Map? 3) Pursuant to Miami Beach City Code 2-484 (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 anot-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. reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYISTIDENTIFICATION: ^ Prod ed ID Form of Identification Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: Florida, minty of Miami-Dade is PRINCIPAL IDENTIFICATION: ~ Produced ID Form of Identification ^ Personally known (Principal) Stat f Florida, Coun of Miami-Dade S rn a sari b fore me day ~ .2008 Gib . -State of Florida Sign~dtrn^c~ofis'ul 1~Y ~j01+1 signature Notarization of EXPIRES October 02, 3011 TO BE COMPLETED BY CITY CLERK'S STAFF C ee: J Yes [ ] No Amount Pald S '~ MCR # Lobbyist Registration Form received and verified by: P:~CLER\LOBBYIST\Lobbyist Registration Form 32TO8.doc a 1-; ~ Paid 27 kNN MOOit~ 31`sWN # DD721090 October 02, 3011 I do solemnly swear that all of the for g facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-48 f the Miami Beach City Code and all reporting requirements. City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 CityClerk@miamibeachfl.gov r- LOBBYIST NAME: l"'~~ ~ 5 `-, - eCM~n2.``t~ I understand that no later than October 1st of each year, I must file the following forms, 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 Form 2) Disclosure 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, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. L Z( Signature: Date: F.\GLERtLOBBYIST\Lobbyist Registration Form 32708.doc CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership.interest in the entity.* KAAMOS, LLC LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE Sinider Miami Beach, Inc. 650 West Avenue, Suite 1712 Miami Beach, Florida 33139 Manager and Member OF MEMERSHIP INTEREST 15% Eclat Holdings, LLC 7511 Miami View Dr. North Bay Village, Florida 33414 Manager and Member Metcalfe Miami Beach, Inc. 1111 Lincoln Road, Suite 400-KLFPA Miami Beach, Florida 33139 Manager and Member Packley, Ltd. Inc. 1111 Lincoln Road, Suite 400-KLFPA Miami Beach, Florida 33139 Manager and Member Enlow, Inc. 650 West Avenue, Suite 2712 Miami Beach, Florida 33139 Member Pommes, L.L.C. 927 Lincoln Road, Suite 118 Miami Beach, Florida 33139 Member Inception39, L.L.C. 927 Lincoln Road, Suite 118 Miami Beach, Florida 33139 Member 25% 20% 10% 10% 5% 15% 1F THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH IND/V/DUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST OFFICERS OF KAAMOS, LLC: Ted Snider 650 West Avenue, Suite 1712 Miami Beach, Florida 33139 Managing Director Jean Francois Mourier 7511 Miami View Dr. North Bay Village, Florida 33414 Managing Director Suzzette Metcalfe 1111 Lincoln Road, Suite 400-KLFPA Miami Beach, Florida 33139 Managing Director Debra L. Packley 1111 Lincoln Road, Suite 400-KLFPA Miami Beach, Florida 33139 Tax Matters Director lF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* SNIDER MIAMI BEACH, INC. CORPORATION NAME NAME, ADDRESS, AND OFFICE % OF STOCK Ted Snider 100% 650 West Avenue, Suite 1712 Miami Beach, Florida 33139 President IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* ECLAT HOLDINGS, INC_ LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE % OF MEMERSHIP INTEREST Jean-Francois Mourier 50% 7511 Miami View Dr_ North Bay Village, Florida 33414 Manager Anette Mourier 50% 7511 Miami View Dr. North Bay Village, Florida 33414 Manager lF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page S 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.'` PACKLEY, LTD. INC. CORPORATION NAME NAME, ADDRESS, AND OFFICE Debra L. Packley 1661 Stony Brook Ln. Morris, Illinois 60450 President, Secretary and Treasurer OF STOCK 80% Thomas F. Packley 1661 Stony Brook Ln. Morris, Illinois 60450 Vice President 20% IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page S 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal- stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.'` METCALFE MIAMI BEACH, IN CORPORATION NAME NAME, ADDRESS, AND OFFICE % OF STOCK Suzzette Metcalfe 927 Lincoln Road, Suite 118 Miami Beach, Florida 33139 President 100% IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* ENLOW, INC. CORPORATION NAME NAME, ADDRESS, AND OFFICE % OF STOCK Mirielle Enlow 650 West Avenue, Suite 2712 Miami Beach, Florida 33139 President 100% IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* INCEPTION39 LLC LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE % OF MEMERSHIP INTEREST Fred Olsson 927 Lincoln Road, Suite 118 Miami Beach, Florida 33139 Managing Member 100% lF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* POMMES, L.L.C. LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE % OF MEMERSHIP INTEREST Alex De Pommes 927 Lincoln Road, Suite 118 Miami Beach, Florida 33139 Managing Member 100% IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. NOTE: Notarized signature required on page 8 6