RES 2015-0761 - Appoint Jeffrey L Cox manager of HuHot Mongolian Grill ---,..,,, :,
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STATE OF NEBRASKA
Pete Ricketts 2015 MAI 28 PM 12: 4445BRASKA LIQUOR CONTROL COMMISSION
.S,,A2' • 4 11, -_- Governor Hobert H.HoPe
Executive Director
' '/ittorr rdto!.., - 301 Centennial Mall South,5th Floor
CITY CLERK RO.Box 95046
Lincoln,Nebraska 68509-5046
MAFil!. NEBRASKA Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352 n-1v)
web address:http://www.lcc.ne.goui
May 28, 2015
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Manager Applications Jeffrey L. Cox
LICENSE -'I-4887 #1-79202, &*1-84430
Dear Clerk:
Enclosed are three copies of a manager application for Jeffrey Cox, in connection with the Huhot
Mongolian Grills, all located in Omaha.
Please present this application for manager to your CityNillage Council or County Commissioners and
send us the results of their action.
Sincerely,
)
Jacqueline Rodriguez
Licensing Division
NEBRASKA LIQUOR CONTROL COMMISSION
402-471-2571
1
encl.
Janice M.Wiebusch Robert Batt Bruce Bailey
Commissioner Chairman Commissioner
An Equal°ppm tunlip Employer
MANAGER APPLICATION Office Use
INSERT-FORM 3c Q' "
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL,SOUTH ',,; ! #""
PO BOX 95046
LINCOLN,NE 68509-5046 ,.,.. ,11 4 Q 'I°
PHONE:(402)471-2571 t l ° 5-1-ON
,
FAX (402)471-2814 t ' `,-� `w., t
Website:WO,w is .te. k
MUST BE:
1 Citizen of the United States, Include copy of US birth certificate,naturalization paper or
current US passport
✓ Nebraska resident. Include copy of voter registration in the State of Nebraska
1 Fingerprinted.Two cards per person,fees of$38 per person,made payable to Nebraska State
Patrol.If printed at NSP mail check only.
. 21 years of age or older
Co o /LLC information
Name of Corporation/LLC - ig
,S,)-(t r1 C t tn'-i'3 XA./G
410
Premise information
Liquor License Number 4 rts 7 7 Class Type
(if new//application leave blank)
Premise Trade Nar e�BA: f,f`+ .. t7 t.t t
Premise Street Address: /Of N . / ?-d Ci . �e...., -r- 66 f ( -1
City; L County: 'o4.7 t.,64r Zip Code: 't' C
cei
Premise Phone Number: 4t e 7- — Q t- if?fa
Email address: 0 r- ►-L.- i,e I a , 6 rt—.k.ei:vie t I. cent^--4-
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals.
ltttp:l wv ,icc.lie.got/licet; sea reiiii a► h. gi
el.."(..
SIGN k R t" QED Cll : t# 1 ! _° y AGM is I:ER
(Faxed signaturesare acceptable)
Form 103
Rev 912013
Page 2 of 6
Mariagi's information must b+e completed below., PLEASE PR NT".CZ :ARI. x, -
.'foist Name: C�1 First Name: �e7`7"r�' MI: L;
Home Address((include PO Box if applicable):
City: - Pa-1 , f i,Q/l • - County ‘.C4fLrjaY Zip Code: 468133.
Home Phone Number. VOA '7 " 75.S Business Phone Number: y0,,2 -,YO-l�S�
Social Security Number: , ,� Drivers License Number&State: _ _ /1�L
Date Of Birth: 'r , „ Place Of Birth: k4 vt4 cl'i$
Email address:3 r fa vi 4fj,04,17c21'
RI JVI� _
axe. `� 7Si aFos`�F•.r,i''a.',^.cr+w Y "�f!'R7&- ?'rove" �.�5 "�"'�jjs ,'A
r�eyou maned?,If,yes,pomp e e sptfus ,„S in totmatlon n if a spousal 4av►, mitt , D
,�,/� MAR 16 2015
5 ❑NO :
N1i:A:A N/A LIQUOR
Pp���rc"rolma'�.iq= .�� .7 .":fffh.xZi' ., la �qta C9"MtS1°tM� - -
First Name: Q e,fir
MI:
p Y �
Spouses Last Name .
Social Security Number_ _ Drivers License Number&State: 1�e -
, , Date Of Birth: Place Of Birth: A 6t,k Ac.,t ue 1 1\1 f l
(J
. °l {{ i a'
PIVIS:
da t7 � ' h 4i ; ';a 0 .tfY * � � 1rt'a W � T �Y
• s -x:
�
r
YEAR YEAR
CITY STATE • YEAR OR CITY&STATE
FROM• FROM TO
® ://;oi /!/0, (2E960 ao/1 P ,�1t Iof\ Ni F . ,goo`i aolil
ik1�' a !) - 9-e,11 ML— 2cOto 2 7
. o t -c ? 'a°tv 0 onct,ha_ tot= ,Woo ? cot�
Form 103
Rev 92013
Page 3 of
•
Arrl
!!` l x 1 r x C� . h :J4C74\ �! � � om 1 t S ' x
���a�tEz9 x:._�....�.tk:�ia
YEAR NAME OF EMPLOYER , NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
//n lam/
/79Frt3PcetI` 12 r7L rn s �n�. . f0.2 S1-'-ri ID
I. READ CAREF
ULLY. ANSWER COMPLETELY AND ACCURATELY.
Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-
participation.
Has anyone who is a party to this application,or their spouse,EVER been convicted of or plead guilty to any charge.
Charge means any charge alleginga felony,misdemeanor,violation of a federal or state law;a violation of a local law,
ordinance or resolution. List the nature of the charge, where the charge occurredmonth of the
conviction or plea. Also list any charges pending at the time of this application. If more than one party, please list
charges by each individual's name.
MAR 16 2015 _
❑ YES NO
NEBRASKA LIQUOR
If yes,please explain below or attach a separate page. CONTROL COMMISSION
Date of Where: "Description
Name of Applicant Conviction Convicted of Disposition
(mm/yyyy) (City&State) Charge
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
•
AYESNO
IF YES,list the name of the premise(s)_
3. Do y
ou, as a m aner,qualifyunder Nebraska Liquor Control Act(§53-131.01)and do you intend to
supervise,in person,the management of the business?
EYES DNO
Form 103
Rev 9t2013
Page4ofb
•
4. List the alcohol related training and/or experience(when and where)of the person making application.
#NLCC Training Certificate Issued: Name on Certificate:
Date
Applicant Name ( YYYy) Name of program(attach copy of course completion certificate)
1 f I „
F C okLp' rc-r�i9 f-� TivGL
•
*For list of NLCC Certified Training Programs see www.lcc.ne,aov/trainin$info.htmt
Experience: -. .' -
Applicant Name/Job Title Date of; Name&Location of Business
- .. Employment:
•,l tr Lk' /14 14 v-l9 fj 0'CL-0.4u L.s' •-
(t Cbx 61"•-• ,µ. l9 re- ?.0 .1
•
5. Have you enclosed Form 147 regarding fingerprints?
ONO
rz103 .
REVJ 15
Page 5 of 6
$03 0r � OgrMl •
The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the
applicant and/or spouse of applicant who makes the above and foregoing application that said application has
been read and that the contents thereof and all statements contained therein are true. If any false statement is
made in any part of this application, the applicant(s) shall be deemed guilty of perjury and subject to
penalties provided by law. (Sec §53-131.01)Nebraska Liquor Control Act.
•
The undersigned applicant hereby consents to an investigation of his/her background including all records of
everykind and description including police records, tax records (State and Federal), and bank or lending
institution records, and said applicant and spouse waive any rights or causes of action that said applicant or
spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or
releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or
indirectly,a spousal affidavit of non participation may be attached.
The undersigned understand and acknowledge that any license issued,based on the information submitted in
this application, is subject to cancellation if the information contained herein RESTEIVVEfitcurate, or
fraudulent. -
MAR 16 2015
ill SKA LIQUOR
r'st""'SION
Si tur of Manager Ap leant Signature of Spo se
ACKNOWLEDGEM NT ;
State of Nebraska _
County of D o K�^i a S The foregoing instrument was acknowledged before me this
• 3 -1 al 15 .. by LA414e- tom%j5c7n
date name of person acknowledged
1/ SU6W M.BAKER`YJ AffixSeal" GENERALNOTARW_
Notary Public signature SEAL
STATE OF NEBRASArk
COMPASSION SIRES S
APRIL SAS 2018
In compliance with the ADA,this application is available in other formats for persons with disabilities
A ten day advance period is required in writing to produce the alternate format.
Fonn 103
.. .. . ..' _: '�. Rev 92013
Page6of6.
. :Prfnt Foirn„
SPOUSAL AFFIDAVIT OF woe use
NON PARTICIPATION INSERT ' '
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIALMALLSOtrrH
PO BOX 95046
LINCOLN.NE 68509-5046 .
PHONE:(402)471 2571
FAX:(402)471-2E 14 '
Website:www . . -
-I acknowledge that I am the spouse•of a liquor license holdet. My signature below confirms that I will have not have any
interest,directly or indirectly In the operation or-profit of the business(§53=I25(I3))of the•Liquor Control Act. I will not
tend bar.make sales,serve patrons,stock shelves,write checks,_sign invoices or represent myself as the owner or in any
.way participate in the day to day operations of this business`.In any capacity: I understand my fingerprint will not be .
required;however,I am obligated to sign and disclose any Information on all applications needed to process this ;
.application.
!t / P.tn (7,6)(
• Signatures spouse askin or waiver -Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of ROIn rzk5 ke-c •_
County of t.At ct U,(.•') = The foregoing instrument was acknowledged before me this
J'
b-i a— c- • by -, �y .
..date 1`t" (� - Oxae of person acknowledged
ill
AffizSeat S09N4At BM�N
IfilA Y e t GENERAL
Notary Public signature gam'
• srAION
EffiRni
NAIL lir0014
•
I acknowledge that I am the spouse of the above listed Individual,'I understandthat my spouse and I are responsible for
compliance with the conditions set out above. If it Is determined that the above.individual has violated($53-125(13))the
Commission may cancel or revoke the liquor license. - , >- - - V
�
crfr` -6,„ -
Si re o divid at 1 involy with application Printed name of applying individual
(Spouse of{ individual listed above) .
State of 1 l . s kc-� •;
County of x tTA.'S ' The foregoing instrument was acknowledged before me this
S-‘- --15 : by 3;-{4re L C'aC"
date (person acknowledged
(` v ��. . -
w .Affix Seal 8U$Nf M.BAKER
CIt l rn .�Qd�-c. t
Notary Public signature SEAL .
8TA1E OF NEBRASKA
COMMSTSON Fla
Apo oQta
In compliance with the ADA.this spousal affidavit of non participation is available in other formats for persons wish disabilities
A ten day advance period is requested in writing to produce the alternate format .
• FORM 35-417S
Revised tf008
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Ci of Wi Omaha, bras a ���°M %N/4,
c.,
1819 Farnam —Suite LC 1 z 1gre t 'i�'�
Omaha, Nebraska 681 83-01 1 2 s ,„,
Buster Brown (402) 444-5550 �� •• `'` �ry
City Clerk FAX (402) 444-5263
TFD FEBR3A
June 9, 2015
Restaurants, Inc. Application to appoint Jeffrey L. Cox
Dba"Huhot Mongolian Grill" manager of your present Class"I"
2101 North 120th Street, Suites C6 & C7 Liquor License location
Omaha, NE 68164
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to
appoint a manager to the liquor license has been set for June 23, 2015 . The City Council
Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic Center,
1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states, "Each applicant
or his/her representative for any type of license shall be personally present in the Council
Chambers, in order that the Council may make inquiries, on the date of public hearing of the
application for said license". Failure to be present at this Council Meeting is grounds to
recommend denial of your application to the Nebraska Liquor Control Commission.
Sincerely yours,
cidoxe.
Buster Brown
City Clerk
BJB:clj
AHA,
City ofOmaha, WjbrasIa ,u xxxillr-f.".11111111V7
1819 Farnam —Suite LC 1 xW h,!� , \
Omaha, Nebraska 68183-0112 0�' .� ° �
Buster Brown (402) 444-5550 ��,o L �'` w�
City Clerk FAX (402) 444-5263 O41D FEB1xt''4�
June 9, 2015
Jeffrey L. Cox Applications to be appointed manager of the
5004 Fountain Drive present Class "I" Liquor License locations for
Papillion,NE 68133 (SEE ATTACHED)
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to be
appointed manager of the liquor license has been set for June 23, 2015 . The City
Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic
Center, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states, "Each
applicant or his/her representative for any type of license shall be personally present in the
Council Chambers, in order that the Council may make inquiries, on the date of public hearing
of the application for said license". Failure to be present at this Council Meeting is grounds to
recommend denial of your application to the Nebraska Liquor Control Commission.
Sincerely yours,
dor
Buster Brown
City Clerk
BJB:clj
MANAGER'S APPLICATION FOR
CCW, LLC 990 SOUTH 72ND STREET 68114
DBA HUHOT MONGOLIAN GRILL
CCW, LLC 17660 WRIGHT STREET, STE 12 68114
DBA HUHOT MONGOLIAN GRILL
RESTAURANTS, INC 2101 NORTH 120TH STREET, 68164
DBA HUHOT MONGOLIAN GRILL SUITES C6 & C7
S
No.
Restaurants, Inc., dba"Huhot Mongolian Grill",
2101 North 120th Street, Suites C6 & C7,
requests permission to appoint Jeffrey L. Cox
manager of their present Class "I" Liquor
License location.
06-23-15;cj
RECEIVED
Presented to Council:
June 23, 2015 - Approved 7'0
Buster Brown
City Clerk