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RES 2013-1472 - Appoint Ronald L Jefferson manager of Elks
otE o1 y a STATE OF NEBRASKA � Dave Heineman n-- j "° NEBRASKA LIQUOR CONTROL COMMISSION �p+ Governor 13 �' Hobert B.Rupe til'! _' Executive Director 301 Centennial Mall South,5th Floor L _ P.O.Box 95046 « Lincoln,Nebraska 68509-5046 t Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 October 18, 2013 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Elks BPO Iroquois Lodge 92 LICENSE #C-01338 Dear Clerk: Enclosed is a copy of a manager application for Ronald Jefferson in connection with the Elks BPO Iroquois Lodge located in Omaha. Please present this application for manager to your City/Village Council or County Commissioners and send us the results of their action. Sincerely, q'CL6F-4412-1—e--;)2,,—)70di22,12,4,Li2J7-?.. 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 Printed with soy ink on recycled paper MANAGER APPLICATION office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH OCT ) 5 2 013 PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE: (402)471-2571 CONTROL COMMISSION FAX: (402)471-2814 Website:www.lcc.ne.gov Corporate manager,including their spouse,are required to adhere to the following requirements 1) Must be a citizen of the United States 2) Must be a Nebraska resident(Chapter 2—006)and must provide proof of voter registration in the State of Nebraska 3) Must provide a copy of one of the following: state issued US birth certificate,naturalization paper or US passport 4) Must submit fingerprints(unless a non-participating spouse)(2 cards per person)and fees of$38 per person, made payable to Nebraska State Patrol 5) Must be 21 years of age or older 6) May be required to take a training course et TN. Name of Corporation/LLC: I. � IJ.P.O. ._] �u U Q I S heck' & Q! Premise License Number: p1 ,new application leave blank) Premise Trade Name/DBA: l S Premise Street Address: of R O f$\ I l h=' coT City: n1 \\A1/4 State: L 1 Zip Code:c O I( 1 Premise Phone Number: 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.aov/license search/licsearch.cgi i - 0 CORPORATE F?C: •NAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of 5 • Gender: 10 MALE ()FEMALE Last Name: J G First Name: c t f Th MI:L Home Address(include PO Box if applicable): (�' 9 I► D' .�� _�3 City: nk 1 rf County: Zip Co Uj...tde: b 0(.. Home Phone Number +"+�' C`pl��rj Business Phone Number: —00.9."4. .6 Social Security Number Drivers License Number& Stater Date Of Birth: _Place Of Birth: © m P hA, 1QQ AYES ONO x�A Spouses Last Name: �C � � First Name: RC,6,1 MI: �--- Social Security Number:_ _ _ Drivers License Number&State; Date Of Birth: Place Of Birth: OI-Y)c ha NE- - I _ CITY&STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO a OrnQ hQ . NC iq ci 3.N3 E,c ELVED o c i 10 1 i Form 103 Rev 11/2012 Page 3 of S NEBRAS A a QUOR dye C.;Oty.i ioN C . YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER bto IT/ (01PCY.3 3—e-ffk6Q atiel. 10 i SeEi-azu 40--(ii7-1106 -Rio Cogestc 0.-1-R- 6 915 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 party,please list charges by each indivi. • 's name. YES 4b, NO I yes,please explain be ow or attach a separate page. Name of Applicant Date of Where Description of Charge Disposition Conviction Convicted (mm/yyyy) (city&state) RECEIVED • OCR. 16 n13 OR NEBRAs U_a QU CO 'ii ;1QW COW1 R 2. Have you or your spouse ever been approved.4 made application for a liquor license in Nebraska or any other state? •! S 0 T 4F.S..listi+rhe ..haf 3. Do you, a�xn" nageracqua ' er Nebraska Liquor Control . ct(§53-131 01)and do you intend to superviAA,j s m agement of the business? ►!4 S ( IO 4. Have you enclosed the required fingerprint cards and PROPER FEES with this application? C•eck or mone order made payable to the Nebraska State Patrol for$38.00 per person) ti S �10 5. List any alcohol related training and/or experience (when and where). Form 103 Rev 11/2012 Page 4 of 5 • 4 . j 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 i 1-d, based on the information submitted in • ' this application, is subject to cancellation if the information co, .ine(he -in is incomplete, inaccurate, or • . fraudulent. / . , j,4 , - ~.61/3„,t4 L— i/ Of ‘‘ 13 ,k1k% qC. I A A , °.: iss , Signature of Mana!- °' �•licant •�.. Si ti, �ure •L TA use ACKNOWLEDGEMENT State of Nebraska County of Th'.:,Kg i-k` The foregoing instrument was acknowledged before me this b@TCaF 12._..Pt, 2O(3 by Jllrl..p L. -t POi5iN L. JeREo"-" iY date name of person acknowledged <--..'.*-7 )- - Affix seal ELE IA.AAei= -.�::' .� ENERN.td GOrtAiMN. Notary Public signature SEAL MU OF NEBRAA tiocenibm 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. C�C,1 A. �p�3 �R Form 103 i�i'� N Rev 11/2012 C'.3 +� j�t3�l:` SO Page 5 of5 �. 'sc SPOUSAL AFFIDAVIT OF Office use RECEIVED NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION 0 C 1 15 2013 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASI,R LIQUOR PHONE:(402)471-2571 FAX:(402)471-2814 CONTROL COMMISSION Website: www.lcc ne.gov w a 'y4.egxr•�m. RcIfl L. Jerferx:sf) Si nature o •u ir if..king for waiver Printed name of spouse asking for waiver (Sp se of individual listed below) State of ZP€ i County of DUi.1il- The foregoing instrument was acknowledged before me this t)C-1-0e -_`Al, ZD byPO43k /J 1 , i%J date name of person acknowledged 0,:ta - s' ;:kC--- Affix Seal a +uARw. l otary Public signature SEAL• SrA1*Of NE914M101 bpkis ast'ts r + A ttli) At,i) L. 3-QvFQD, 014.. • Signature of individual invol th application rinted name of applying individual (Spouse of individual listed above) State of 11/4-1 County of DO i(Ct 1,-Ptc The foregoing instrument was acknowledged before me this DCTO -2—9 , 20 i by DNI t,ID L. JE date name of person acknowledged l • • Affix Seal NdtaryPublic signature / >1111AL $T*II OF 11Elri*lA.. . . In compliance with the ADA,this spousal affidavit of non participation is available in other formats for pe ns 14 A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1/2008 OMAHA, NIrB City ofOmaha, Webraska .� 1819 Farnam—Suite LC 1 Ili -.' +t n Omaha, Nebraska 68183-0112 0�� ; � • Buster Brown (402) 444-5550 .o City Clerk FAX (402) 444-5263 o� � 41'Fp FEBR �� October 23, 2013 Elks BPO Iroquois Lodge 98 Application to appoint Ronald L. Jefferson Dba"Elks" manager of your present Class "C" Liquor License 2420 Lake Street location Omaha,NE 68111 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 November 5, 2013 . 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, Buster Brown City Clerk BJB:clj ��MAHA, NF6 CityofOmaha, Webraska .�NI 4, 1--. /5\rpiaej 1819 Farnam-Suite LC 1 n®. 4 Omaha, Nebraska 68183-0112 0,e- >� ',_ ;', Buster Brown (402) 444-5550 ti' City Clerk FAX (402) 444-5263 o••eb p FEBRt•44 October 23, 2013 Ronald L. Jefferson Application to be appointed manager of the 2577 Manderson Street present Class "C" Liquor License location Omaha,NE 68111 for Elks BPO Iroquois Lodge 92, dba "Elks", 2420 Lake 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 November 5, 2013 . 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, ,te4t Buster Brown City Clerk BJB:clj No. Elks BPO Iroquois Lodge 92, dba "Elks", 2420 Lake Street, requests permission to appoint Ronald L. Jefferson manager of their present Class"C" Liquor License location. 11-05-13;cj V RECEIVED Presented to Council: November 5, 2013 - Approved to"O Buster Brown City Clerk