RES 2014-1517 - Appoint Daniel J Eusebio manager of Chartwells 4 EKE SrgTF'' _ C E t Y L U
y4koz- STATE OF NEBRASKA
d, . �,14 .*, , Dave Heineman �� y i9U `+ 22 NEBRASKA LIQUOR CONTROL COMMISSION
Governor Hobert B.Rope
\,4, - .!K .`= Executive Director
�`" cu t".sb 301 Centennial Mall South,5th Floor
I-.' CLERK P.O.Box 95046
(l M A H A. N E B tR A S K t. Lincoln,Nebraska 68509-5046
Phone(402)471-2571
November 24, 2014 Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352 CITY)
web address:http://www.lcc.ne.gov/
Omaha City Clerk
1819 Farnam
Omaha NE 68183
RE: Compass Group USA Inc dba Chartwells, liquor license Class I - #110648
Dear Clerk:
Enclosed is a copy of a manager application for Daniel J Eusebio in connection with the
above referenced liquor license.
Please present this application for manager to your City/Village Council or County
Commissioners and send us the results of their action.
Sincerely,
NEBRASKA LIQUOR CONTROL COMMISSION
Mary Me man
Licensing Division
Enclosure: Manager Application
cc: file
Janice M.Wiebusch Robert Batt William F.Austin
Commissioner Chairman Commissioner
An Equal Opportunity Employer
Printed with soy ink on recycled paper
. . . . .
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MANAGER APPIACATION ' C1Mcc TA° ..
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INSERT-FORNI3c
ri Er„;;E WEE
NEBRASKA LIQUOR CONTROL COMMISsION
i 8 2014 .
.301 CENTENNIAL MALL SOIITTI NOV ;
?O B0X95046
LINCOLN,NE 68509.15046 •
PHONE:(402)471-t57I • NEBRASKA LIQUOR
. CONTRof rom"!!6SION
F02)471,2814 • • •
Website:www:lemne.voit i
;
MUST RE: . 1
"ir Citizen of:the'United:States include-dowel-CIS birth•eertifIcate,anturaliiatioti paper or. !
current US passport
V Nebratlen:resIdent. Inclutle zopv Ofvotenregistrationin the.State orNebraslca
4' #ingerprIntal.Two cards:Perperson,:.feeS•of$38per person,made payable to Nebraska State
Petrel.if prititedat NSF mall cheek-only.
ir :21 years-of age ror older
g.'..dgii,gfielP4§,4:4:YeatiMetirettigligiggRARtritgialWeitligtagielWaggini ,
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iiame:of.Co4)oration/LLC: GOPql%"54, C vidv12 05 A ,Inc, - - - .
MilinartrigiartgAMEMErlifitifigaZigilMitEriteNEFEREKEI
1 1 Us Li g --i--
Liver LiceriSeNumber: Class.Typc
111noNitpplicntlanienve.1)1=10
J?cl ce-A 7 •
Premise Trade:Name/Mk. 0 ttiM1X41 .t.A-P>. .
• . .'Premise-Street.Address: ... -C7bi.-) '' ''''41 anki>
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City.: .. .01k>CAlA1k :County:-DeVt,bik5 Zip Code:.1,4510id
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Premise:Phone Number: 4012.- 7914•.2.40 ,
Email.address; • 641A,l'APt:P.. c*Iktt-ac.fit
J ;The indilidual'whose raine Is listed as a corporate Officer or managing member*IS reported:oil-insert
form.3a or 3b .or listed with the Commission, Click on this link to see authorized:indbiiduals.
.1ittpdtimmIce-ne.eovilicense searehllitseftreh,-ctii
/1 i 444144 . 1
A.MC:IAtiti044:070$0013r0.00; QAWMOVE1600AA,:NAMV:0101V.Mtil.
(faxed Signatures are-acceptable)
Tann 103 1
RI:4'9/2013
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RIND`-�CI�T 4RU�'
�Ianiai+�s 7nformatlanRmustAbe completed`belgw�,P.�,.EASE�P, _.,,..
Ezlse,bto
'First Name: �}i3y ltt 1 MI: 3Last N ame: b t.' _
Home Address(inelude'PO Box.if applicable): 31�- SW i t'� `�' ks AYE.
City: 1 % •County: QV .ir'S Zip Code: sett
Home Phone Number. 407.21:(o411•9S_ Business Phone Number: ?—- 4
Witgok
Social Security Number.
Drivers.License Number SE.State;_ =11
Date Of Birth:_______—,--:--;-------
Place OfBirth: j.q5H`tl co t7)4 , 1�7.e
Email address: &v&- e.0411.1P ID CJ�w -,.•USG, . ram
•i3iiT iEf uig 12:f9 fl�Ont(R Cn�Ff arspgusal ititaa vitas bFeF.:sZS tted
I,p�e�'ro�n`azi�d�if.yes,_con� I •. _
03YES ❑NO
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�Sp,�use�s zii�OFinatto3�.�:�-" . �
Spouses LastName: .:1.,P'5 ID First Name; :V U :t r4A, "MI:
Social'Security Number: Drivers-License Number*State: '
Ael1)215.1.*k
Place Of:Birth: 4 .� ►'� , '\fd
1 Date°Qf Birth: i
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! y,1',.1'ti..?a+LY':t� � .«.... .aesc .a. .ttsCss...rf,..r��....�.a.�u.r.�. .it...f'.i'rs':_..
YEAR
YEAR, AR ',&,,STAY ` .
CITY&STATE .,l r:',Yf ►<7 FROM { TO !
FROM' TO �(�slt � I
k1 , ' 1t c.AlkA ! IR • '14)ID •t f+31 �_ , h : 70 it? -Lt.te r- I
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Form 103 I
Rev9;«013
Pagc3 of6 j
NOV 1 E 2014 III
NEBRASKA L1QUO1
CONTROL COMMISSION !
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r t" *T�'N�.GERY,R Tr ftVO_IVIP 3 R :;, :._.._ti...::i.`#r.,,,,i !-:.a..?... ...
tl-- ^-7! 1.17'S1�
- TELEPHONE
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
TO Cf�rj t •�� .
1 ` ?Wet £Jt�J 0 l71 AI -q • '2T6
20ty Ct rh C - &awl" 4Qt
1. READ CAREFULLY. ANSWER COMPLETELY.Al+A`D 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'thcirspotse.EVER been convicted of or plead:guilty to.any charge.
ordinance 'Listthett or,violation federal
Cr state yeartion of a
l law,
or plea. tAls litP ty,,p
conviction or plea. Also list any charges_ ending at the time of this application. 'if more than.one at lease list
.charges by.each individual's name.
TZ YES NO b2,1 t i, b,
If yes,please-explain below or attach a separatepage,
Tate of Where Description
of Disposition
1 Name•ofApplicant Conviction Convicted Charge
(mnilyyyy) (City&State)
I 1
` a
NOV I 2014
CuN • i Lit °' ` ;j
2. .Hays;you or your spouse ever been.approved or made application fora liquor license in Nebraska or ••
anyother state?
i
DYES [MNO 1
IF YES,list the name of the.premise(s):
1
3. Do you,as a manager,.qualify under Nebraska Liquor Cantrell Act(§53-131.01)and.doyou intend to
supervise,in person;the management of the business?
DYES QNtO
Torre 103 1
Rev 92013 i
Pngo 4 af4_
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4. List the alcohol related training and/or experience(when and where)of the`person making application.
{ Name on Certificate: ____.- C1`C\
*NLGC Training Certificate Issued: A�N C —'��
Q,`-
Applicant Name Date Name of program(attach eery of course completion certificate)
Date Nara::
*For list of NLCC Can ad iiningProgramssecwwrc•,lee.ne.ernhrninineinfo:html
Experience: Date-of ,
Applicant Name/Job Title Name&Locatian af.3usiness:
PP Employment:
►V V1 ?Q14 I
7tL ta .t/Irynf� l I ir
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5 Have you enclosed the required fingerprint cards andTRO►FER FEES with this application? '
(Check br•money order made:payable to the Nebraska State Patrol for S35.00 per person)
EYES NO ,fie 1 n subm r1f ed-bN Web taste-Sta47e 1 ro 1
• g - fn�,r-rIPt& ()Jere, rollea. I
e es U)h�n 1
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Rcv912013
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Par 5 ors
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PERSONAL,OATH AND CONSENT OF INV..ESTIGATI01'!1
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
every kind 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 he 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 is incomplete, inaccurate, or
fraudu lent.
A-k.
Signat c of Manager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of , teit 6 S The foregoing instrument was acknowledged before me this
3 11-� `/� by ,..,C:i'C\S"++E.. k L_Sc'-(')% +
date name of person acknowledged
•t.i. `�r-.� Affix Seal
Notary Public signature loSIBE RAi.KtlihRY-State at itettraska
CAROL GLEASON
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.
PA �� Form 10?
d(, to R/ !tee 9.^013
0f t Page 6of6
Nov 18 20 i4
441 wS1nr,r
r4744 rl 7 s71*IiSONslf EOATH-AlS'D C6- SE.RT OF
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-I31.01)Nebraska Liquor Control Act.
The undersigned applicant hereby consents to an investigation of his/her background including all records of
every Lind 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 is incomplete, inaccurate, or
fraudulent.
6(,)
Signature of Manager Applicant ignature of Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of j The foregoing instrument was acknowledged before me this
it-6c- s)oi4 by IY\e AN. `y
date name of person aclmowtedged
a-CZK— ^141e "�\ Affix Seal,
Notary Public signature GEN;Ar4L 11DTAlratatt of ktbraska
CAROt.R G EASON
c Canft EgLJuKt.2ttft
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.
RECE V ; '
Form 103
Rev 912013
NOVN 1 8 2014 Page 6of6
Nil . ASKA LIQUOR
CON_ko_ _ COMMISSION
I.' ,.Pont Rim i
SPOUSAL AFFIDAVIT OF I011).::VIA! RECEIVED
NON PARTICIPATION INS ER.I.
NEBRASKA LIQL:012 CONTROL,COMMISSIOS NOV 1 g 2014
'la i CENTENNIAL MALL SOUTH
ro!lox 9 MW,
LINCOLN.NE 6.S.109-3041,
rlIONt. (402 471-2571
FAX (4921-1'71-«314
SKcAo iviLliCtolUsOsPcoN
CONTROLf‘IEBRA
, .. .
I acknoWledzei:thataiiiiAhe spouse of a liquor.ticensetolden.My signature below confirms that I will have not have any
interest,directly in theOperatiOn:Orpriiifli:Of ihe:btiSiness'( 53.;125(13 )ofihetitittor Control Act. 1 will not
tend bar,int'ikeknie4•Sen,e'paticiiiiS:-: tbak Slie1eS.1.;'Write..elieekS.7.:Silin involees Or represent myself as,the owner or in any
way participate in theilailto day.op6rations'prthi$,,I*iles,jo:;iny czlriacity •I understand my fingerprint wilt not he
required;lioW4i4rA4riioblieated to Siiriatidedisdbitntt.iiiii -1,ation on all applications needed to prOCCSS this
apPlicotion;2, ,,...$,,„ :.-.:!,„-..1,,..:;.,'.-:, .;;!-: ::,,,, -"A; :,14.-;,..,:.,.., ,.•:''...:.':—. :. -, .... - ,. , ,
; i • • i i
1 r,; , , '; „I .,, ,...-; ; ,, •;,-; i
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---- —
Signatures.tif spouse asking for waiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
Suite of
County of ..,..."")01/41tkE25.; The foregoing instrumen-,was acknowledged before me this
, .
1.1 - "7 - 1 Lt c,.....1. , .../12,:,...r\._ ,_-_-'--\,--f?...t.--`{-).._,_r..,1... ____
d...ac• IA 3 or Of persor;ote*.roo SetIpz:.:,
".., i
a49 ,4--)...a..&. 2-(e.,-..—.) 1 Aff,,s,...!
R ,
SEWAL ISIDARY4latt at istrasta ;
Notary Public signature i
i .o. tact.R GLEM014 •
*Cams.tea.Atf i.EMT •
I tieknoWtedee''..'iliart urn the spouse of the eheve.listed;indiiiiiiiat, I understand that my spouse and I are responsible for
compliance W ..hi"conditions set out above.If it.is determined that,the above individual has violated(*53-115(13))the
Comm' -lo ;tiny -mu:el'or revoke the litioc.10 ic:onse;
\k‘ 1
I L.____,,./
SiiMatilie(1indik)dut4n1,viy{.- 'iiii ippli4...alion Printed nanic of applying individual
(Spouse of isiditidual listed above)
1
State of . ttk
Counts'of i"i6J--)16itS The fOrCOith instrument',vas acknowlekined before me tins
.11/0q
_ 1,'Llfay....n.J, r S'c.., 2 LAI' ) i . .
____... by__Dali:ti.. _.,.J. UE Volk)
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/ A,•••:5-;,t,,,,....) (7;//-/—),•-- ,7'-;.747 I AI rr, 1
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GEER&NDTARY.State et Nebraska
L-:-1----- --t, I .1 ABIGAIL G.HEADLEY
i Notary Public signature--
1 ..d,':144:1 MY Comm Exa.&wary 9,2018
-
la COW:Pit:VIM With Ow ADA,Itai tqW.Wial arfidJ vit.of non j•.1.rls,:tivioro iAe 4,1111.:lif WI Ptii'!1:71114irl,lot ri:1,.(11,4‘..-4t3 Ju,abi law),
A Ito day ACIVITICT reniod it toqu:,1a.i.i vilittriv tu rirchttax'tr.'sItcrr,41,..fernug.
FOR Nt
• liViSC1.3 I'ZOOS
, - ..,......,............,,,.............m............,..-,,,
No. /5%�
Compass Group, USA, Inc., dba "Chartwells",
7000 Mercy Road (Mercy Hall; Hixon Lied &
Hilmer Art Gallery Buildings on College of St.
Mary's Campus), requests permission to
appoint Daniel J. Eusebio manager of their
pending Class "I" Liquor License location.
(NOTE: City Council approved the Class "I"
Liquor License application on November 18,
2014).
d V
12-09-14;cj
RECEIVED
Presented to Council:
December 9, 2014 - Approved 7 c
Buster Brown
City Clerk