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RES 2014-0778 - Appoint Carol J Broer manager of Kelly Inn - Omaha 2gE ST.rr ,, q" STATE OF NEBRASKA "' Dave Heineman ,; NEBRASKA LIQUOR CONTROL COMMISSION . i 'W a Governor # '° - Hobert B.Rupe d!ae� �s6�= Executive Director 301 Centennial Mall South,5th Floor P.O.Box 95046 Lincoln,Nebraska 68509-5046 Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 June 2, 2014 MS USER 800 833-7352(rTY) web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Carol Broer LICENSE #I-62965 Dear Clerk: Enclosed is a copy of a manager application for Carol Broer in connection with Kelly Inn-Omaha, located in Omaha. Please present this application for manager to your City/Village Coceil or County Commissioners and send us the results of their action. Sincerely, Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION 402-471-2571 encl. Janice M.Wiebusch Robert Batt William F.Austin Commissioner Chairman Commissioner An Equal Opportunity Employer Printed with soy ink on recycled paper I Apr 21 1403:25p p.2 • • MANAGER APPLICATION O#1ioeUee INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION APR 2 4 2014 301 CENT gNLAL MALL SOUTH PO BOX 95046 LINcoLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 FAX:(442)471 71-2 CONTROL COMMISSION Website:www icc.ne.gov MUST RE: Citizen of the United States. Include cow of US birth certificate. current US oassport �t�1��4a.1�lPeT�r ✓ Nebraska resident. 'winds cony a voter ree j ation in St ele tsle of Nebraajta Fingerprinted.Two cards per person,fees of S38 per person,made payable to Nebraska State PatroL If printed at NSF mail check only. 1 21 years of age or older AllhOtatiarraiNtil MOM Name of Corporation/LLC: `Vs mick Lk.)tsk 1I.e1oktr es r i ea�` ' �, =Si.�3'-""'�,�� �} ,,_,r�-c��, fi � '���s�.s��58`�''"�� ems+.-..,��r.�r.:r�,•;�-. Liquor License Number. (dip raci to 5 Class Type (ifaew application leave blank) Premise Trade Name/DBA: 1 f 11 u Z'r h Q r VA.h Ct-„, Premise Street Address: Lk./ La tbSe I O d+11 City: C)re os, County: ebe tit 14 S Zip Code:103 f 3 Premise Phone Number: i b a - 3 S Q - t`1 4 t3 Email address: The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed Wdth the Commission. Click on this link to see authorized individuals. htto://www.lec.ne.goy/licease searcJh/licsearrh,ctri REQ r I• , I ;y C e • OFFICER.I:MANA.ON ER (Faxed signatures are acceptable) Form 103 1111 4112mF5 1400011064 Last Name: \r O`e.Y` First Name: COOL MI: Home Address(include PO Box if applicable): ' \ B 2 &hu, v, City: C) \O► County-. 0 O1.5 Zip Code: Lo 2 ) c Home Phone Number - - 5 D 5 Ic Business Phone Number:401c - 3 3 . 14 0 0 Social Security Number:_ _ , _ _) Drivers License Number&State: Date Of Birth: _ _ Place Of Birth: tor 4-0 Email address: Q.\(jr t i. C-0 limmumaimmommaimmaammaismaimarapFt D ❑ YES ►o� NO APR242014 NFtt a ©"LIQUOR IS$ion Spouses Last Name: First Name: MI: Social Security Number: Drivers License Number&State: Date Of Birth: Place Of Birth: YECITY& STATE � YE� CITY& STATEYE S YEAR FROM TO FROM TO Or oa\ cx ` \t. 19'96 01014 Form 103 Rev 92013 Page 3 of 6 YEAR TELEPHONE FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR NUMBER aooS au), �A.&_Q �Y p. 1Dav� 'R3a-� '�8�-Oq [9q b auu 5 '� S Q, '►v`o►\c, - 3c5-d io 9 1. READ CAREFULLY. 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 alleging a 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 occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. If more than one partL_pkvitib charges by each individual's name. REel YES ix NO APR 2 4 2414 If yes,please explain below or attach a separate page. NEBRASK►LIQUOR Date of Where Description CONTROL COMMISSION 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 PP q any other state? 14YES ONO IF YES,list the name of the premise(s): J C CtY k 3. Do you, as a manager, qualify under Nebraska Liquor Control Act(§53-131.01)and do you intend to supervise, in person,the management of the business? AYES ONO Form 103 Rev 9/2013 Page 4 of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. • *NLCC Training Certificate Issued: 'e,1"3. a Name on Certificate: CO 'b -e Applicant Name Date PP (mm/ yy) Name of program(attach copy of course completion certificate) Cc . N o -x, tea lo�ol0 l r arihln. �t�nA-� � RECEIv APR 242014 NEBRASKA LIQ OR CONTROL COMM SSIOP *For list of NLCC Certified Training Programs see www.lcc.ne,gov/traininginfo.html Experience: Applicant Name/Job Title Date of Employment: Name&Location of Business: CAr o 1 bh e-cJ1 — Co V`C 1 O- 1 as-aoaq 1?s4- w.e v>_ h .5raotTnK `1 oto . 10 10 84k �Si Omahu`i1l6 to8r31 5. Have you enclosed the required fingerprint cards and PROPER FEES with this application? (Check or money order made payable to the Nebraska State Patrol for$38.00 per person) KYES E]NO Z�%'& `i)Y t v\-\-5 G \NI . Form 103 Rev 9/2013 Page 5 of 6 The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the applicant and/or spouse of applicant who makes the above and foregoing application that said application has been read and that the contents thereof and all statements contained therein are true. If any false statement is made in any part of this application, the applicant(s) shall be deemed guilty of perjury and subject to penalties provided by law. (Sec §53-131.01)Nebraska Liquor Control Act. The undersigned applicant hereby consents to an investigation of his/her background including all records of every kind and description including police records, tax records (State and Federal), and bank or lending institution records, and said applicant and spouse waive any rights or causes of action that said applicant or spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or indirectly,a spousal affidavit of non participation may be attached. The undersigned understand and acknowledge that any license issued,based on the information submitted in this application, is subject to cancellation if the information contained herein is incomplete, inaccurate, or fraudulent. Lira i-Al.Q f313-e--&-V'c--) Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of ,y. s The foregoing instrument was acknowledged before me this Zz. A.PR+,... Z.o -t by 4=1..--%1P-..m Q date name apemen acknowledged /�; A sea +�►$ 1 4 lily�/ Notary Public signature 1 IU40try fonrariOn E May 7.2014 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. RECEIVED APR 242014 NEBRASKA LIQUOR R ? CONTROL COMMISSION 5°fs A A A - - T y Yxeoettto to o cext f carke to g iget oucceo&(icy cotspletiott of an apputtteci btaissist.cowtoe e 22, 2O1C cetttiPriabt io valid fart Mxee gea a i y Xodett 2 Mispe - &ecutiue`dixectex . p t 301&atesutia t.Mall Saud,5"t Ytaoac £meta.,NE 685(19 v — v v r y - y y -- v 0 O�?Za�a � 00,NHA, City We bras a . �i f .. l 1819 Farnam—Suite LC 1 2 , rJt t'i Omaha, Nebraska 68183-0112 0.4- A , :'. Buster Brown (402) 444-5550 A ti' City Clerk FAX (402) 444-5263 041'FJ� FEBRt.4- June 10, 2014 Kelly Midwest Ventures, L.P. Application to appoint Carol J. Broer Dba"Kelly Inn- Omaha" manager of your present Class "P'Liquor 4706 South 108th Street License location Omaha,NE 68137 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 24, 2014 . 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. Sincere yours, eidmaci Buster Brown City Clerk BJB:clj F°MAHA, NF8 CityofOmaha fAle6raskg �° die 1819 Farnam—Suite LC , Omaha, Nebraska 68183-0112 0�� 1.11..... - Buster Brown (402) 444-5550 .o " ti' City Clerk FAX (402) 444-5263 04 �• TFD FEgRU� June 10, 2014 Carol J. Broer Application to be appointed manager of the 7883 Bauman Avenue present Class "I" Liquor License location Omaha,NE 68122 for Kelly Midwest Ventures, L.P., dba "Kelly Inn-Omaha", 4706 South 108th Street 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 24, 2014 . 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, ,6(4140104), Buster Brown City Clerk BJB:clj Kelly Midwest Ventures, L.P., dba "Kelly Inn— Omaha", 4706 South 108`h Street, requests permission to appoint Carol J. Broer manager of their present Class "P"Liquor License location. 06-24-14;cj RECEIVED Presented to Council June 24, 014 - from; - �- Buster Brown City Clerk 6/24/2014 Enterprise Mail-Liquor License hearing Kelly Midwest Ventures LP Liquor License hearing Kelly Midwest Ventures L.P Carol Broer <cbroer@kellyinns.com> Tue, Jun 24, 2014 at 12:10 PM To: cjohnson3@ci.omaha.ne.us Can you please reschedule my hearing for managers application of the liquor license for Kelly Midwest Ventures on June 24, 2104, I have a scheduling conflict at work, and can not get away.Can you reschedule for July 1 , 2014, thanks for your consideration. Carol Broer General Manager Best Western PLUS Kelly Inn Omaha 4706 S 108th Street Omaha NE 68137 (402) 339-7400 (Phone) (402) 339-5155 (Fax) (402) 319-9899 (Cell) cbroer@kellyinns.com www.bestwesternkellyinnomaha.com https://mail.g oog le.corr✓mail/u/0/?ui=2&i k=cd387c45eb&Hew=pt&search=i nbox&th=146cedb99d361 ba5&si m1=146cedb99d361 ba5 1/1 s No. 7-7 a Communication from Carol J. Broer, pending manager for the Class "I" Liquor License of Kelly Midwest Ventures, L.P., dba"Kelly Inn— Omaha", 4706 South 108th Street, requesting the application be laid over to July 1, 2014. 06-24-14;cj 03 VIC{ / RECEIVED Presented to Coun.-1• f� June 24, 2014 - �m ch ur on fk Buster Brown City Clerk 1