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Home My WebLink AboutSugar Drop Shop LLC ECEIVEQ SEP 1 5 2010 \ \\) CIty 01 Sunny 19101 Beach Office 01 tile ct Clerk Skatepark Management, Events, Camps, Sales, Lessons, and More....... "Skater Family Owned and Operated" Rene Lecour (Owner) 305-967-8767 Office 305-249-1806 Fax 786-537-2016/786-537-3372 Cell suga rsd ropshop@vahoo.com www.sugarsdropshop.com Report: Profit & Loss Page 1 of 1 Sugars Drop Shop LLC Profit & Loss January 1 - September 3, 2010 Income Gross Receipts Total Income Expenses Insurance Payroll Expenses Rent or Lease Supplies Supplies & Materials Taxes & Licenses Total Expenses Net Operating Income Net Income Total 129,277.03 $129,277.03 968.00 9,660.51 4,274.08 13,862.25 482.19 965.19 $30,212.22 $99,064.81 $99,064.81 Friday, Sep 03,201009:20:22 PM PDT GMT-7 - Cash Basis https://qbo.intuit.com/qbo lIreoorts/118731389/execute?rntid=118731389-P ANDL-view-12... 9/4/2010 Report: Page 2of2 Company Snapshot My Income My ExptnHI I Tllnv_....... 1ot11:$121,271.o) I ~.y_..... TOCItS3G,212.21 !'!lI!U!!Um -- -- 5129211.13 lltICorLNIe S417~08 -- . "66051 PrwiOUI Yilt IncorM Companson Previous YHr ElptnM Compartson ~IM___ "I ~t".&cco.a"l 5.10001 " $il1000. 1 .. u " to . I I I '" ... .... .. ". ... '" .. '" ... .... .. ". ... '" Dc I- I :tOle I- I :M10 Who OWes ... Wllo I OWl YMc.r'f"enfrlwweno......,iIwOicn.. YOII twmIIy hIft 1M) outstiMlng..... httos://abo.intuit.com/cl/v36.140/118731389/reoorts/execute?rntid=118731389-COMP SN... 9/4/2010 Sugars Drop Shop Sugars Drop Shop is a family/skater owned and operated company based in Miami. Florida. At the present time we manage three skate parks for Dade County Parks and Recreation and each park has its own mini pro/snack shop. We also organize skate clinics, camps. host several charity events and a variety of skateboard contests in the South Florida area. Our goal at Sugars Drop Shop is to infuse honesty. integrity, creativity. pride and passion back into the business of skateboarding. Although we are a relatively young company we have been able to achieve a lot in a short period of time due to our grassroots approach to business. a punk rock do it yourself attitude. and a serious love for all styles of skateboarding. We see our parks as the center of each skateboarding community and with so much negative influence in the world today we feel called upon to guide our young skaters down the right path. The focus of our business is not just about making money. we do it because we love to skate. we love those who skate and because we have witnessed firsthand the positive impact that a well run skate park can have on our children and our communities. Ultimately, our mission is to shine a brighter light on the "rebellious non sport" that we love; and at the end of the day it feels good to know we are helping get kids stoked on skateboarding. I Skate and Educate All of our parks offer free Saturday morning skate clinics that we have customized to fit the needs of all skaters. so no matter if you are on a beginner, intermediate or advanced level we have a program to fit any skaters needs. We also offer camps that range from three hour mini camps, school holiday camps and our popular Road Trip Camp. Besides teaching the fundamentals of the sport we also focus on the history of skateboarding, balance, park etiquette. stretching techniques, board maintenance and the latest tricks. Our coaching staff consists of positive role models whose backgrounds include; professional skateboarding sponsorships. Ten years of action sports camp instruction. National Youth Sports Memberships and current AED/CPR certification. With over 15 years in events planning. hosting and promotions experience we can cater to any style function. Our focus is on family friendly skate contests and charity events that are not only fun but safe and well organized .In the past we have worked on projects with The Florida Family Resource Center. 91.9 The Call F.M. Radio. Mattel Toys. Capitol Records, Homeless Food Collections; worked with several local youth organizations and countless skateboard companies. We host an annual Christmas Toy Collection, a annual three day Skateboard Rodeo. a quarterly four part contest series. and we host free skate jams on Go Skate Day every June 21. .We are also working with the City of Miami on their Bike Days/Open Streets Project where we will be adding a bmx/ skateboard/scooter demo. free skate lessons and a mini contest to their event. ...... pro skater Steve Berra Road Trip Camp I ! Free Skate Clinic Community Services Youth Mentoring at Bay Point Boys School ~ J Free lessons for the foster kids of the F.R.C. J Skateboard Recycling programs Holiday Skateboard Hookups Balance board demonstration at Florida City Elementary Schools Career Day References for Sugars Drop Shop LLC Donna Diaz Miami Dade Parks Manager West Wind Lakes Park 305-388-4771 Linda Baker Miami Dade Parks Manager Country Village Park 305-622-2594 Mary Shie F emandez Program and Events Coordinator Village of Palmetto Bay 305-234-6383 Dino Congelio Promotions Director DNA Energy Drink 1-724-366-9864 Mike Liebler Youth Director Elevate Skate 786-205-2005 Rene Lecour Summary of Qualifications: . More than 10 years of experience as a youth leader. . More than 10 years of experience as a sports coach. . Strong organizational and event planning skills. . Highly skilled in skateboard training programs. . Excellent relationship within the skateboarding community. . Ability to efficiently run a skate park. . Ability to efficiently run a full service skate shop/ retail store. Work Historv M.L. Productions: Events Coordinator South Dade Christian Church: Youth Director Coconut Grove Skate Park: Programs Director Sugars Drop Shop: Owner Operator (skate parks and retail store) Volunteer Historv West Kendall Pop Warner: Football Coach Westchester Optimist: Baseball Coach South Dade Christian Church: Youth Director Bay Point Boys School: Volunteer Youth Mentor Miami-Dade Regional Juvenile Detention Center: Guest Speaker Memberships . National Youth Sports Coaches Association. · West Grove Skate Club: Founder/ Skateboard Coach. Additional Historv . · Developed and implemented skate camp programs for several youth clubs including; Police Athletic League and Florida Resource Center. · Provided a skateboard safety program to Florida City Elementary. · Collaborating with the City of Miami on their Bike Days Miami/Open Streets Project. · Assisting and partnering with fundraising and development for several non for profits and youth programs. PAYROLL Classification Employee Total Hours ESTIMATED DIRECT EXPENSES: SUMMARY Monthly Cost Proposal Est. Hours/Mon. Concessions Skate Goods Park Liability Insurance Misc Expenses (HelmeUBoard Rental Upkeep) : } !/"--' i--- RenEi Lecour Owner C:IUserslyilkalDocumentsl Cost Proposal Avg. Hourly Rate 192 $8.00 192 rotal Estimated Payroll = Total Estimated Monthly Payroll Total Estimated Monthly Direct Expenses Total Estimated Monthly Cost = Sugars Drop Shop Cost Estimate Labor Cost $1,536.00 $1,536.00 $ $ $ $ 800 1,000 120 50 $1,970 $1,536.00 $1,970.00 $3,506.00 ~1 ~ 20P Date 91212010 3 Admissions Mon - Fri. Sat. - Sun. Holidays and School Days Off Rentals Helmets Skate Boards Concessions Sodas Water Gatorade Chips Assorted Candies Rice Crispies Brownies Honey Buns Hot Dogs Cotton Candy Ice Pops and Ice Cream Mini Pro Shop Skate Boards Grip Tape Trucks Wheels Hats & Beanies Shirts Bearings Hardware Shoes Misc. Skate Accessories C:\Users\yilka\Documents\ Cost Proposal Sugars Drop Shop Price Structure SUMMARY Proposed Price Structure Price $2.00 $5.00 $5.00 $2.00 $5.00 $1.00 $1.00 $1.50 $0.50 $.25 to $1.00 $0.50 $0.50 $0.50 $1.50 $1.00 $1.00 to $2.00 $35.00 to $45.00 $5.00 $35.00 to $45.00 $25.00 $15.00 to $20.00 $12.00 to $20.00 $7.00 to $15.00 $4.00 to $7.00 $40.00 to $60.00 $.25 to $20.00 9/7/2010 3 These are a few pictures of our shop located at the Westwind lakes Skate Park. We started out with a rusty, beat up 8x20 shipping container; which is very similar in size to the building being constructed Sunny Isles Beach Skate Park. The shop contains a display/service counter, three beverage coolers, shoe rack, snack display, three skateboard racks, t shirt display, storage closet and cubby shelves for our customers back packs. Our goal was to create an ultra hip, full service retail shop where kids would be able to come in, grab a snack, watch a skate video, repair their boards, chill out, listen to some cool music and catch up on the latest skateboarding chatter. I -_.~-,-----_..- OtlOC .,n.....L'liillBmDV II v ror -l 'il <( a!lll WUI II = ,uw, 1:= \I J ! , II .......1 II I I gl ~I <<'-II I ~ i I i .- .... .... ".-.-. " , l! L ~ J r~ I I I~ II II I ;il ~ II , -\ , . - . ,- a :l . ... I" ~ II ~ i .1 . ... f ~ in , in I i I 0- j i ! 4lW ,I Ii 11 ! I I I ~ lill II 1 ;:0, {J>n II II II ' r I I' 1)1 II \::5 Ii II Ii II I I I.....-U 11 II II , iI il a !I "Jl """ € ill i' II II !I II lL-1I lL-1J l'iT \() :c. .1; , 'lll5 ~+ I, ~ ( I.! :;;.,.:.0, jl .,!t ~ ~ Ja\ooJ !' i x< ~ II'I ~ I I" @ z I ........- <IL J " t ---.l (L I ~) M ~ x x 0 ~t ~ 0 I J lk.. r I I ~ ~ (Ql \UJ IOl """ "- Ii ----1J PROPOSAL FOR: Skate Park Management PROPOSAL This proposal puts forth possible ideas to use our company to manage your skatepark. The key feature will be to allow Sugars Drop Shop to bring in competent adult coaches whose backgrounds include; professional skateboarding sponsorships, 10 years of action sports camp instruction, National Youth Sports Association Memberships, a million dollars worth of liability insurance and current AED/CPR Certifications, to serve as positive role models, provide skate clinics/camps, lessons, organize competitions and family events. In addition to those advantages our company will also provide a small Pro-Shop where skaters can purchase premium skateboarding equipment at budget prices. We do this because being skater owned and operated we feel that skaters on all economic levels should have the opportunity to purchase quality merchandise at an affordable rate. OBJECTIVES #1 - Give skaters a safe and clean environment for families to enjoy the activity of skateboarding. #2 - Effectively enforce all safety regulations such as: Use of Helmets, Proper Skate Etiquette, Stretching Techniques, and Board Maintenance. #3 - Provide families with a healthy and intense activity. Where skaters of all ages can practice the art of skateboarding and are given a creative outlet for their energy. Methods The primary methods for achieving these objectives: . Provide 1,000,000 Liability Insurance and Accidental Insurance . Charging a reasonable entrance fee. (Lower than most area skate parks) . Providing rental equipment such as: Helmets and Skateboards . Keeping ramps and skate area free of debris. . Provide Concessions and Pro Shop . Offer Lessons/Camps/Demos/Contests and Clinics .Pav Sunny Isles Beach a monthlv concessionaire fee of $450.00 Parks We Are Currently Working With West Wind Lakes Park (MDC Parks) South Dade Park (MDC Parks) Country Village Park (MDC Parks) In closing we look forward to working alongside you to better enhance your patrons skate park experience. We welcome any questions and or concerns. Please feel free to contact us at anytime. Sugars Drop Shop ::'''~01JV rEm IL-~'1'J'L(;:1rm~'ijti]~ ~'E ': ml;]~_ D!::I:.D-!.EZ.!El~(>io;.lTille ~ ~:IB~.s:;; [? .::lEJ.IED, ~?: IE3i:E-JUo @:1;WL~@=!~'-:"~=;; 81m ~', ~ ['}[~I:TI~~;[JIt.:i}(;J.!.\~:".0r;::-I-;-:':.~~1 '.... ''1.r ~"-""l. r~-- "-'r, r~ :.. .,. ~ ':'1 . ~J r:\!r;t:m:X[;:r~(cro;l.JIj1;\/ '~\-'b.!._c.c If.3.;L1.-, - ",,",l.r~lJl.l111 ~~~>~.~~:. ~ M .. DO NOT FORWARD SUGARS DROP SHOP 105 GRAND AVE CORAL GABLESFL 33133 PA'tIIEffiRECEIVED ~~COUNTYT~ Ii" 1111111111111111111I111111111111,1111 IiI llIlillll II I .1" ill I :____S~E_O!.H~~S~~___ __ __.___-____ ____._ _____ __ _______J ~osed Contact Persons Rene Lecour ( Owner) -NYSCA Certified Coach -Skate Park Manager for 3 years -Skate Park Management Company Owner for 1 year 105 Grand Ave Miami, FL 33133 786-537-3372 305-967-8767 Yilka F errera (Manager) -NYSCA Certified Coach -Skate Park Management Company Manager for 1 year 12931 SW 117 ST Miami, FL 33186 786-537-3372 Electronic Articles of Organization For . Florida Limited Liability Company Article I The name of the Limited Liability Company is: SUGARS DROP SHOP LLC L09000094480 FILED 8:00 AM September 30,2009 Sec. Of State jbryan Article II The street address of the principal office of the Limited Liability Company is: 105 GRAND AVE MIAML FL. 33133 The mailing address of the Limited Liability Company is: 105 GRAND AVE MIAMI, FL. 33133 Article III The purpose for which this Limited Liability Company is organized is: ANY AND ALL LAWFUL BUSINESS. Article IV The name and Florida street address of the registered agent is: RENE M LECOUR . 105 GRAND AVE MIAML FL. 33133 Having been named as registered agent and to accept service of process for the above stated limited liability company at the place designated in this certificate, I hereby accept the appointment as registered agent and agree to act in this capacity. I further agree to comply with the provisions of all statutes relating to the proper and complete performance of my duties, and I am familiar with and accept the obligations of my position as registered agent. Registered Agent Signature: RENE LECOUR Article V The name and address of managing members/managers are: Title: MGR Yll.KA I FERRERA 12931 SW 117 ST MIAMI. FL. 33186 Signature of member or an authorized representative of a member Signature: RENE LECOUR L09000094480 FILED 8:00 AM September 30, 2009 Sec. Of State jbryan 00258 01/08/10 l"J DEPARTMENT OF REVENUE I 23-8015257581-7 Certificate Number II Certificate of Registration II Issued Pursuant to Chapter 212, Florida Statutes DR-11 R. 01/10 QUARTERLY I. Filing Frequency 01/06/10 11/10/09 Opening Date Registration Effective Date This certifIeS that SUGARS DROP SHOP LLC 105 GRAND AVE MIAMI FL 33133-4839 has met the sales and use tax registration requirements for the business location stated above and is authorized to collect and remit tax as required by Florida law. This certificate is non-transferable. POST THIS CERTIFICATE IN A CONSPICUOUS PLACE ,. THIS IS YOUR SALES & USE TAX CERTIFICATE OF REGISTRATION""' i) (DETACH AND POST IN A CONSPICUOUS PLACE) ~ ~ REFER TO THE BACK OF THIS SECTION FOR SPECIFIC INFORMATION REGARDING YOUR COUNTY'S TAX RATES. {} THIS IS YOUR ANNUAL RESALE CERTIFICATE FOR SALES TAX Note: New dealers who register after mid-October are issued annual resale certificates that expire on December 31 of the following year. These certificates are valid immediately. DR-11 R, R. 10/09 " lXPARTMENT Of REVINlJE I 2010 Florida Annual Resale Certificate for Sales Tax I THIS CERTlRCATE EXPIRES ON DECEMBER 31, 2010 DR-13 R. 01/10 Business Name and Location Address Reoistration Effective Date Certificate Number SUGARS DROP SHOP LLC 105 GRAND AVE MIAMI FL 33133-4839 01/06/10 23-8015257581-7 This is to certify that all tangible personal property purchased or rented, real property rented, or services purchased on or after the above Registration Effective Date by the above business are being purchased or rented for one of the following purposes: . Resale as tangible personal property. . Re-rental as real property. . Incorporation as a material, ingredient, or . Re-rental as tangible personal property. . Incorporation into and sale as part of the repair of component part of tangible personal property . Resale of services. tangible personal property by a repair dealer. that is being produced for sale by manufacturing, . Re-rental as transient rental property. compounding, or processing. This certificate cannot be reassigned or transferred. This certificate can only be used by the active registered dealer or its authorized employees. Misuse of this Annual Resale Certificate will subject the user to penalties as provided by law. Use signed photocopy for resale purposes. Presented to: (Insert name of seller on photocopy) (date) Presented by: Authorized Signature (Pun:hasef) (date) DATE (MMlDDIYY) 10/1/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION FOR SERVICE CALL: ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. FRANCIS L. DEAN & ASSOCIATES, INC. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE 1n6 S. NAPERVILLE RD., BLDG. B COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. BOX 4200 COMPANIES AFFORDING COVERAGE WHEATON, IL 60189 (800) 745-2409 COMPANY STARR INDEMNITY & LIABILITY COMPANY www.fdean.com A INSURED SPORTS AND RECRECATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND ITS PARTICIPATING MEMBERS: COMPANY B Sugars Drop Shop COMPANY 6805 Southwest 152 Avenue Miami, FL 33193 CERT. #P1GL-102025-01 C COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co POLlfJ EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE MMlDDIYYl DATE IMMlDDIYYl LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 1,000,000.00 A f-- X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ 1,000,000.00 I CLAIMS MADE 00 OCCUR P1 GL-1 00000-01 11/1/2009 11/1/2010 PERSONAL & ADV INJURY $ 1,000,000.00 OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000.00 f---- X INCLUDES ATHLETIC FIRE DAMAGE (Anyone fire) $ 300,000.00 ..- PARTlCPArITS MED EXP (Anyone person) $ 5,000.00 ~OMOBILE LIABILITY COMBINED SINGLE LIMIT $ I-- ANY AUTO ALL OWNED AUTOS BODILY INJURY $ :== SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY I-- NON-OWNED AUTOS (Per accident) $ I-- PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY -EA ACCIDENT $ - _ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ ==j ,UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKER'S COMPENSATION AND IWCSTATl}. I 10TH- EMPLOYERS' LIABILITY TORY LIMITS ER EL EACH ACCIDENT $ THE PROPRIETOR! RINCL EL DISEASE - POLICY LIMIT $ PARTNERSlEXECUTIVE OFFICERS ARE: EXCL EL DISEASE - EA EMPLOYEE $ OTHER Total Certificate Premium: $937.50 DESCRIPTION OF OPERA TlONS/LOCA TlONSNEHICLESlSPECIAL ITEMS Skatepark and Cheerteading Activities CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Sugars Drop Shop BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE 6805 Southwest 152 Avenue HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTICE Miami. FL 33193 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Prancis L. ([Jean ACORD 25-5 (1/95) @ACORDCORPORATlON1988 ADDITIONAL INSURED I Date (MMlDDIYY) 10/112009 AGENCY PHONE 800-745-2409 APPLICANT (First Named Insured) I Phone (AIC. No. Ext): (AIC. No. ExI): FAA 630-665-7294 (A1C. No.): Sugars Drop Shop FRANCIS L. DEAN & ASSOCIATES, INC. 6805 Southwest 152 Avenue 1776 S. NAPERVILLE RD., BLDG. B Miami, FL 33193 P.O. BOX 4200 WHEATON, IL 60187 I CO/PLAN EFFECTIVE DATE I EXPIRATION DATE CODE: I SUBCODE: 11/1/2009 11/1/2010 AGENCY CUSTOMER 10 POLICY NUMBER: P1GL-100000-01 ACCOUNT NUMBER: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER - Miami Dade County I BUILDING: X ADDITIONAL INSURED LOCATION: - 111 NW 1 Street, Suite 2340 I BOAT: LOSS PAYEE VEHICLE: - Miami, FL 33128 MORTGAGE SCHEDULED ITEM NUMBER: - OTHER LIENHOLDER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER X ADDITIONAL INSURED Mobile Mini, Inc LOCATION: I BUILDING: - VEHICLE: I BDAT: LOSS PAYEE - MORTGAGE SCHEDULED ITEM NUMBER: - LIENHOLDER OTHER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER I ADDITIONAL INSURED LOCATION: I BUILDING: LOSS PAYEE VEHICLE: I BOAT: - MORTGAGE SCHEDULED ITEM NUMBER: - OTHER LIENHOLDER - EMPLOYEE AS LESSOR - ITEM DESCRIPTIDN: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER - I BUILDING: X ADDITIONAL INSURED LOCATION: - I BOAT: LOSS PAYEE VEHICLE: - MORTGAGE SCHEDULED ITEM NUMBER: - LIENHOLDER OTHER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER - I BUILDING: X ADDITIONAL INSURED LOCATION: - I BOAT: LOSS PAYEE VEHICLE: - MORTGAGE SCHEDULED ITEM NUMBER: - LIENHOLDER OTHER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER X ADDITIONAL INSURED LOCATION: I BUILDING: - LOSS PAYEE VEHICLE: I BOAT: - MORTGAGE SCHEDULED ITEM NUMBER: - LIENHOLDER OTHER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: INTEREST I RANK: NAME AND ADDRESS I REFERENCE #: I I CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER - X ADDITIONAL INSURED LOCATION: I BUILDING: - LOSS PAYEE VEHICLE: I BOAT: - MORTGAGE SCHEDULED ITEM NUMBER: - LIENHOLDER OTHER - EMPLOYEE AS LESSOR - ITEM DESCRIPTION: SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a) FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS. 1. This s)t~rn stateme~t is submitted ~ \ to L \ \-'/ o::r S l ~ "y --L~-\ e.. <; ::r~~i~~(:~\J~;~~ ~ocJ\ ~O( ,S~Za:\-~b,d Por\( WhOS~USGS ad~s is. {\ \6~ ,a.. Ve (\\\0.('('\\ I ~L ~~\3>~ and (if applicable) its Federal Employer Identification Number (FEIN) ~1-080~~ \ 7 (If the entity had no FEIN, include the Social Security Number of the individual signing this sworn statement: 2. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 3. I understand that "convicted" or "conviction" as defined in Paragraph 287. 133(1)(b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contenders. 4. I understand that an "affiliate" as defined in Paragraph 287. 133(1)(a), Florida Statutes, means: a. A predecessor or successor of a person convicted of a public entity crime; or b. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity come. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity CrIme In Florida during the preceding 36 months shall be considered an affiliate. 5. I understand that a "person" as defined in Paragraph 287. 133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of any entity. 6. Based on information and belief, the statement which I have marked below is true in a relation to the entity submitting this sworn statement. (Please indicate which one (1) of the following three (3) statements is applicable.) ~ (1) Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. a(2) The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or any affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. tL (3) The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management of the entity, or agents who are active in management of the entity, or any affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order by the Hearing Officer determined that it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor list. (Attached is a copy of the final order.) I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER PERIOD IS LONGER. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR THE CATEGORY TWO OF ANY CHANGE IN THE IN ORMATION CONTAINED IN THIS FORM. ~ <'e- \.-e-( al J( (Printed or Typed Legal Name of Affiant) .. STATE OF FLORIDA ) )ss. COUNTY OF MIAMI-DADE) Th fore oi9g Form was acknowledged before me thi~171.y o~1"lM4'2e1O, by f.U.,OV ~ , as O(.;CJ ~ ^' f of ~A 't> L Va Florida corporation, on behalf of said corporation and limited partnership. He/She personally appeared before me and is personally known to me. AI1' ~1Ic... Notary Public State of Florida ~ ~ '" Stanley Moore ;, c .; My Commission 00826464 'Vto,r.:,f Expires 09/2812012 NotMY:tiiIt~ Print Name;.6 JI 00 '-.\.. _ Notary Public, State 0 Florid;'ft &. h My Commission Expires: y, 1--0 bOI t/ I I - NON-COLLUSION AFFIDA VIT STATE OF FLORIDA COUNTY OF MIAMI-DADE The undersigned being first duly sworn as provided by law, deposes, and says: 1.1. This Affidavit is made with the knowledge and intent that it is to be filed with the City of Sunny Isles Beach City Commission and that it will be relied upon by said City, in any consideration which may give to and any action it may take with respect to this proposal. to make this Affidavit on behalf of, (Name of Corporation, Partnership, lndi' aI, ft:.), a corporatio duly organized and existing under the laws of the State of ~\C(" \ 00. of which he is 0 LUN' (" (Sole Owner, Partner, President, etc.) 1.3. Neither the undersigned nor any person, firm, or corporation named in above Paragraph 1.2, nor anyone else to the knowledge of the undersigned, have themselves solicited or employed anyone else to solicit favorable action for this proposal by the City, also that no head of any department or employee therein, or any officer of the City of Sunny Isles Beach, Florida is directly interested therein. 1.4. This proposal is genuine and not collusive or a sham; the person, firm or corporation named above in Paragraph 1.2 has not colluded, conspired, connived or agreed directly or indirectly with any Proposer or person, firm or corporation, to put in a sham proposal, or that such person, firm or corporation, shall refrain from Proposing, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference with any person, firm or corporation, to fix the prices of said proposal or proposals of any other Proposer; and all statements contained in the proposal or proposals described above are true; and further; neither the undersigned, nor the person, firm or corporation named above in Paragraph 1.2, has directly or indirectly submitted said proposal or the contents thereof, or divulged information or data relative thereto, to any association or to any member or agent thereof. \<e(\e.. \ ~r 0L l( AFFIANT'S NAME 0\ 1 ) (\p_{ AFFIANT'S TITLE - The foregoing Affidavit was acknowledged before me thi~(1JI day of~~lO, by ff...A..J IE. ~ COu Ii.- , as !J wA.J.€/\ of )() ftJA ) VI\..{) fJ )/./01 tLC .-- a Florida corporation, on beh;lf of said corporation and limited partnership. He/She personally appeared before me and is personally known to me. { NOTORIAL SEAL} ..."..,~~ Notary Public State of Florida r.. ..~ Stanley Moore ~ c ~i My Commission 00826464 ~ 0, f\P'" Expires 09/28/2012