RES 2014-0221 - Appoint Karen A Bouckaert manager of Moonshiners Bar & Grill r kris srr
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' STATE OF NEBRASKA
Dave HeinemanV ° I L i :, NEBRASKA LIQUOR CONTROL COMMISSION
1* ' t. . �' Governor 1' Hobert B.RUpe
etrrl1, Executive Director
301 Centennial Mall South,5th Floor
1 PO.Box 95046
f Lincoln,Nebraska 68509-5046
Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
January 27, 2014 TRS USER 800 833 7352(1"IY)
web address http.//www,lcc.ne gov/
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Moonshiners Bar& Grill
LICENSE #C-100475
Dear Clerk:
Enclosed is a copy of a manager application for Karen Bouckaert in connection with Moonshiners Bar
& Grill 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
402-471-2572
encl.
Janice M.Wiebusch Robert Batt William F.Austin
Commissioner Chairman Commissioner
An Equal Opportunity Employer
Pnnied unth soy ink on recycled paper
MANAGER APPLICATION Office use
INSERT-FORM 3c -
,RE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 JAN 1 5 2014 2
104
304
LINCOLN,NE 68509-5046
PHONE:(402)471-257I t""t .
ON
FAX:(402)471-2814 �t"R C3f"11 ''f°1 O SS
.►Website: www.lcc.ne.gov . CO T
MUST BE:
✓ 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
✓ 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
' - a -`
�
Name of Corporation/LLC: }f v1/4)5 t ,t i c
I
Liquor License Number: 00 ki 7 5Class Type C,
(if new application leave blank)
Premise Trade Name/DBA: C .:v 5II Ae k Gam' I I
Premise Street Address: q 5)3 9 5) Q 5 4 C. 7"
City: 0✓IA 4 F1 County: a&) I c:�J Zip Code: (p 72,2 7
Premise Phone Number: Ye'2 - a-Y - 50 5 0
Email address: CodOA 5 5141,, C r
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.
http://www.lcc.ne.gov/license search/licsearch.cgi
GN TIMVRE 41 4, I)BY COP ... ./ G.
(Faxed signatures are acceptable)
l Form 103
Rev 9/2013
Page 2 of 6
1400000366
r
a
Last Name: C)LAG ICcA ,t } First Name: j o M1: /4
Home Address(include PO Box if applicable): 5/ y7 50 /12 fk S
City: C)/4,1 k c County: c, ,r cf, Zip Code: J �3
Home Phone Number: 59Business Phone Number: 1Cl2- y's- '1 - Soso
Social Security Number: ,rivers License Number& State: •
Date Of Birth: Place Of Birth: 0/4/1
Email address: /filf
r �k �S* ^ r
�..,�
Q YES t71 NO
5 2014
a* � +a �� �'"a'�a �� c �'` '`�' "�`- '�1 =r?°`�7"a�u.?�„43����.�..�.
`,:.,� � �' ` �° . "'a�;a<
Spouses Last Name: First Name: MI:
Social Security Number: Drivers License Number&State:
Date Of Birth: Place Of Birth:
CITY & STATE YEAR YEAR CITY& STATE YEAR YEAR
FROM TO FROM TO
Form 103
Rev 9/2013
Page 3 of 6
4 ' °s°x'v ,,' r ¢. 3) 1 ' � " .a; l :4 :**:4.* e
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
lc19'1 54. 1-F emialattei
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 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 `a please.list.
charges by each individual's name.
❑ YES NO
JA i I 5 2D14,
If yes,please explain below or attach a separate page.
Date of Where Description l' fiel"tlf"t r'rl4t{"1 tt
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?
OYES NO RECEIVED
IF YES, list the name of the premise(s): JAN 272014
NEBRASKA Q R
3. Do you, as a manager, qualify under Nebraska Liquor Control Act 0530€ I03 )iiiiiiikl /0°`.
supervise, in person,the management of the business?
DYES ENO
Form 103
Rev 9/2013
Page 4 of 6
4. List the alcohol related training and/or experience(when and where)of the person malciEn7 :tVni ti L-24-
*NLCC Training Certificate Issued: Name on Certificate: AN 1 4 2014
^tune --nt
k) 6ED
Date l
Applicant Name Name of program(attach copy o course completion certificate)
Onin/YYYY)
*For list of NLCC Certified Training Programs see www,lcc.ne.gov/traininginfo.html
Experience:
Applicant Name/Job Title Date ofName&Location of Business:
Employment:
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)
SY E S ENO RECEIVED
,i4N1 2 7 ?I:14
NFBRASKA LIQUOR
CONTROL
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 incorn tee 'M ecurate, or
fraudulent.
JAN 5 ?14
N
E #t1hO ►
'f Akiwront eTtfutlifttint
Signature of Manager Applicant Signature of spouse
ACKNOWLEDGEMENT
State of Ne raska
County of _ 0j.4 9kt : The foregoing instrument was acknowledged before me this
�',+ r l� C r^* r r� c' /` by ,4i ' 6a `
name of person acknowledged
°+w4 Affix Seal 04001111
Notary Public signature 01.1tope14.107.111,t
cow
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
N 9
' w #9 Form 103
Rev 9/2013
Page 6 of 6
CONn-,p C t F"1 1+'✓ ,j6 c {3 �° (y F:`'..
4 0MAHA, NF8
CityofOmaha, We6raskg ;�\ 1 I
,rr J,,„
1819 Farnam—Suite LC 1 vr i� r
Omaha, Nebraska 68183-0112 \o® r
Buster Brown (402) 444-5550 .o no"
City Clerk FAX (402) 444-5263 0R41
ED FEBR)t*41-
February 11, 2014
Bar Guys—Nebraska, LLC Application to appoint Karen A. Bouckaert
Dba"Moonshiners Bar& Grill" manager of your present Class"C" Liquor
9523-9525 "Q" Street License location
Omaha,NE 68127
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 February 25, 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,
dA0441
Buster Brown
City Clerk
BJB:clj
oM�HA, N4,4
City of
Omaha, Webraskg 1.-kc:41IF.1147
v,ir
1819 Farnam—Suite LC 1 f �r r` '' �
Omaha, Nebraska 68183-0112 o :3 ,,,^,.. ' ",_
Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263 O 'TE p FEBR�r4A
February 11, 2014
Karen A. Bouckaert Applications to be appointed manager of the
5742 South 112`h Street present Class "C" Liquor License location
Omaha,NE 68137 for Bar Guys—Nebraska, LLC, dba
"Moonshiners Bar& Grill", 9523-9525
"Q" 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 February 25, 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,
44r4 .°41
Buster Brown
City Clerk
BJB:clj
of
/1(
No.
Bar Guys — Nebraska, LLC, dba "Moonshiners
Bar & Grill", 9523-9525 "Q" Street, requests
permission to appoint Karen A. Bouckaert
manager of their present Class "C" Liquor
License location.
02-25-14;cj
iv
/
RECEIVED
Presented to Council:
February 25, 2014 - Approved 7 0
Buster Brown
City Clerk