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RES 2012-1527 - Appoint Justine J Petsch manager of Bemis Center for Contemporary Arts 4-4 ,, ATF�144 R E 1., E I '/ E rJ STATE OF NEBRASKA "� 'dal• �, y NEBRASKA LIQUOR CONTROL COMMISSION � f �,•,� Dave Heineman tqa :; '��. 1„•. a.a Governor Hobert B. Rupe 4 11 12 OCT 25 rim u: 52 Executive Director 301 Centennial Mall South,5th Floor P.O.Box 95046 ° CITY CLERK Lincoln,Nebraska 68509-5046 0 M A N/, NEBRASKA Fax(402)471-2814 or(402)471-2374 October 22, 2012 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: Bemis Center For Contemporary Arts LICENSE #IK-084061 Dear Clerk: Enclosed is a copy of a manager application for Justine Petsch in connection with the Bemis Center For Contemporary Arts 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, C►c� 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/Affirmative Action Employer Printed with soy ink on recycled paper Nebraska Liquor Control Commission. Sincerely yours, e:i"ddleO ) Buster Brown City Clerk BJB:clj do.,. or Oc mac`' Zole by Kelly V\SeS name of person acknowledged �y • /J G J Affix Seal ska Notary` ublic signature '9'61 Al r-Stste of ring ---k'- Gregory a Gering - Ify Comm.Bp.Jan.18,2016 0l,aokrio viedga , ailt is iof ioftll o •' ictdf dual: understand> m spouse aud.I are responsible or j: 1comipliance , i ,; ,,o,•„;rt Y detersninedrthat WPi. ,: i ` ` 'vrnlated( 53..12S(13))the •'byui` cmato.im.:!`J.A�.�i, ,-14h .o_, B w iquor�!tc.�,.{_ "'tddi'+i�i ,,,; t �i,i,Ang ni°t"tfk'.`-.rs'r ^r`e2�`'e�l�ti ,Ct rlr- f :,,,I,, ,ts+:J. va..l.i n7t !fir! �,.�. �-� io-��,a �;;>��i+l r• .H� I�t • t ii ° S. J —� e. Si a, , - of�ividual involved with application Printed nfte of applying individual - "use of individual listed above) State of /V ehrcckti County of 00 1/x, The foregoing instrument was acknowledged before me this 1‘� A , nI' Oc.Lle r. ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 ---R MANAGER APPLICATION . office Use EGNCE) INSERT-FORM 3c OCT 2 2 2012 NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NEBRASKAL.tQ PO BOX 95046 CONTROL COMMISSION UOR LINCOLN,NE 68509-5046 PHONE: (402)471-2571 FAX: (402)471-2814 Website:www.lcc.ne.gov N:T K 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 �1 �ormat1 s "' r S y E s 5 k F k ;fin,, ?<a �� *A; � ,.4,, r�,`f'f ,�, �,��,.�q t Y*' i `4 4.s t .:'. ,K '., k �,.�} 8F mtt'4 yKF#�' i4 fL � — F cga,zew 14' n . . •a!, ' .+�. 5v n �. ''" �t ti.'u n Ky� l flY sr' h y .w„ +�� . -om�.'�.v .4,.:. .u ?•r .._ ,r�_.'`�4.''_.� ..cr2`,. Name of Corporation/LLC: rr/US elAVA /Pk t il4S T1 C ; +x p'3�"S _ 1P �a -�.S � `, r3`5`9�•s..s,> _Y H�' a t es r ash 3�'Xt-g i. r..; J a r $ } '�"' ^� ... 'UC^'k fit 4y ,� { .'..13.. 4S.0 .F,*'�.^d: � _2�i�.. N + .:`.: '& 1t r,�y. '="J, .'•'° �" „�.: 6�Fp.S �'„ ' ��g f 4 Wt .' ` Premise License Number: ' % I / (if newAppiii9n leave lank Premise Trade Name/DBA: 7 u S tio�'2 7` /'2 D1 ig Premise Street Address: ` craedi 7 47- 4- City: A�Q.J State: il/ Zip Code: !7 0/72 Premise Phone Number: 4273///— 9/✓d 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. • httn://www.lcc.ne.gov/license search/licsearch.cai _71-1—;(; f2,1,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 • ��PJ I f:6 '#' �1 € ^�3 @ s i t.ii 1"`v, ').4. p`�{'�1 "?�T �r B. t {ai 4' ..r 7 r "� C ice+r y iy Rti:. !r �a „ i� _i. s�Zia 'r % Y 1- i • a� � t�i.. .,� .. i ,. �1 SSS,,,�, :. [ �� U I .0 'i' fa 'J,d t `�-.., + s�r �+'JZ :. h y.: �$ ` Sri • 4 I .14r, �t ,. r .k: a ,. 40..•. u.:Hrii.@4 'R t :a1rs.,... t;}'.fi„�.+C'` .� ::.;'� .xr. Gender: ®MALE efFEMALE Last Name: jeii S(M First Name: Jit S MI: J Home Address(include PO Box if applicable): )/210 &h1'i pv,ead City: / ,/�j/[ County: Qi.te-Jed Zip Code: 4t10 Home Phone Number: t 21, /e7..6''I Business Phone Number: la 5171/ 1/13 ) Social Security Number: ;r_ _ .. _ Drivers License Number& State::._ _ - Date Of Birth: - Place Of Birth: ,��? �I /V�/� 1 5'a§ -y-v W M'r� -� f •F g AF 41J�+ n1 0 'ry t, . ZS rki7c'i' e n�� "° � e o i � S e'a • 4 re ® ea ' '-@ R s •e 2aA a • f1$ a p � o- :1-11 �';'' j i,^-�''"Y� �-'d } � �;,,, e.i. a >n s Cf�SFa , rd tr�F0liatetcw, z_.r ?" —OAP e4r,,r, ?'s i ✓ urro„k .ate-" OYES O 0 nrT 2 2 ZO1Z x WIT- v t^ a o-e T a s ae s a .z 1; ori • s. fnF ti ,'$dCS,�h+.Y .Y. �F'.':i ..._�!3r£ra''?.':•-;r N3�-��§��,,f. `i.,�,''`',..-� r, .��. .«.r.-r�',.�r,... F�. :��N...m,. .. _ �� c •, Spouses Last Name: First Name: MI: Social Security Number: Drivers License Number& State: • Date Of Birth: Place Of Birth: r6 •..S P4r"y l7 �" a. E�1` � i�^•i ��t �' ..'S f �^' �" � m , ,.-t F-E^3 M`'Po '� ...�-:� EI1 ? ,n � rrai,�.s CITY&STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO orhill2)/ P' 2DI v 2o1 Z e / zoos 20 It) I rvii/l, 1.101 Zoos Form 103 Rev 11/2012 Page 3 of 5 with the Commission. Click on this link to see authorized individuals. • httn://www.lcc.ne.gov/license search/licsearch.cai _71-1—;(; f2,1,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 . YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 7M1 2iJ11 c-r Caroms- 14-e Vge.r-F lip 2.-fit -lof o Poi Zo 11 (II wli.d-Uri -t� --. &- aid %kr •3" qp2.-leti-8q16 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 individual's ame. 9YES 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) FiFCEIVED ' - OCT 222012 liEREASHALQUOR COMP i#A COMMISSION 2. Have you or your spouse ever been approved ade application for a liquor license in Nebraska or any other state? OYES O IF YES,list the name of the premise. 3. Do you,as a manager,qualify under Nebraska Liquor Control ct(§53-131 01)and do you intend to supervise,in person,the management of the business? ES (TO 4. Have you enclosed the required fingerprint cards and PROPER FEES with this application? eC eck or mone order made payable to the Nebraska State Patrol for$38.00 per person) S �10 5. List any alcohol related training and/or experience (when and where). i'l Form 103 Rev 11/2012 Page 4 of 5 Y&STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO orhill2)/ P' 2DI v 2o1 Z e / zoos 20 It) I rvii/l, 1.101 Zoos Form 103 Rev 11/2012 Page 3 of 5 with the Commission. Click on this link to see authorized individuals. • httn://www.lcc.ne.gov/license search/licsearch.cai _71-1—;(; f2,1,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 oiffo vo' m 4,af 5„��.� .sYiTT � ku� �*�,,,r^ £{,� xi ty�-� 'k �n:+ a i` �`' ,� 'c".. n�' .'i�"Y-�*- V 4 sli'� sf ^S^.'�r.�,: emu. :o�a1'kY+ .>1"t e , :h %.,2'' 4 `- v '' �. dii 2« uf 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. r 'gnature of Manager Applicant Signature of Spouse . ACKNOWLEDGEMENT State of Nebraska County of (tt.,/1+ 5 The foregoing instrument was acknowledged before me this ( J ( aF fit, Z(2- by AtAs—firm C-- I SC f date I Kama of person acknowledged C11:1V 46 -t Affix Seal otary Public signature jaiGeoneral Notary•State of STEPHEN E.BEROGREN My Comm.Exp.Nov.al.2015 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 OCTy 222012 N�� Ka ��y��R Form 103 CORE ®�COMMISSION Page 5 of 5 ,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 . CIty /Of dinti nfiy A it- ' \ ebias - a A, .411/4 / ..„0.0_,,,ALP,f, 0 A 0.‘;,-‘ ) ,4:1, h 9 er 1819 Farnam— Suite LC 1 �'Arco,t/ 1 '' `'`4. 0._ i� Omaha, Nebraska 68183-0112 ®«,.� -:s, _ { .;; ' Buster � row (402) 444-5550 st , -0__ __ ;I,, City Clerk FAX (402) 444-5263 0,�b � ,��+�• November 6, 2012 Bemis Center for Contemporary Arts Application to appoint Justine J. Petsch 724 South 12th Street manager of your present Class "I" and Omaha, NE 68102 Catering Liquor License location De ar 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 20, 2012 . 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 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, --1(4#',,,ds' Buster Brown City Clerk _ BJB:clj r n this application, is subject to cancellation if the information contained herein is incomplete, inaccurate, or fraudulent. r 'gnature of Manager Applicant Signature of Spouse . ACKNOWLEDGEMENT State of Nebraska County of (tt.,/1+ 5 The foregoing instrument was acknowledged before me this ( J ( aF fit, Z(2- by AtAs—firm C-- I SC f date I Kama of person acknowledged C11:1V 46 -t Affix Seal otary Public signature jaiGeoneral Notary•State of STEPHEN E.BEROGREN My Comm.Exp.Nov.al.2015 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 OCTy 222012 N�� Ka ��y��R Form 103 CORE ®�COMMISSION Page 5 of 5 ,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 czty o ii (efit eoras,- a &A Art ,r�1ta 9� 1819 Farnam—Suite LC 1 lark e Omaha, Nebraska 68183-0112 ® s � Buster Zrowrn (402) 444-5550 • _ City Clerk FAX (402) 444-5263 4A ® v►�` November 6, 2012 Justine J. Petsch Application to be appointed manager of the 420 Cottonwood Avenue present Class "I" and Catering Liquor Milford, NE 68405 License location for Bemis Center for Contemporary Arts, 724 South 12`h Street Omaha,NE 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 20, 2012 . 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 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 or Control Commission. Sincerely yours, --1(4#',,,ds' Buster Brown City Clerk _ BJB:clj r n this application, is subject to cancellation if the information contained herein is incomplete, inaccurate, or fraudulent. r 'gnature of Manager Applicant Signature of Spouse . ACKNOWLEDGEMENT State of Nebraska County of (tt.,/1+ 5 The foregoing instrument was acknowledged before me this ( J ( aF fit, Z(2- by AtAs—firm C-- I SC f date I Kama of person acknowledged C11:1V 46 -t Affix Seal otary Public signature jaiGeoneral Notary•State of STEPHEN E.BEROGREN My Comm.Exp.Nov.al.2015 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 OCTy 222012 N�� Ka ��y��R Form 103 CORE ®�COMMISSION Page 5 of 5 ,1 p CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 11/2012 Page 2 of S 1200020183 ao/2 by ronx u) Ses date name of person acknowledged Gt_ /70" Ant Seal _ . _ ublic signature — 8 ERA1 IOTA81f�e of*basks isieGregory A.Gartrell In compliance with the ADA,this spousal affidavit of non participation is available to other throats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate format- FORM 354178 Revised U2000 i=ECEIVE !: :: Form 103 OCT 112012 Rev1t/2012 Page s or s hr. �� LitaIUOR CONTROL COMMISSION 000 2012 • , . . :ri• _ r,ECElv Eli .,.: Form 103 OCT 1 1 niz Rev 11/2012 Page 3 of 5 WEBRASCIV4 LIQUOR CONTROL COMMISSION , . - . retary Form 103 Rev 11/2012 Page 2 of S 1200020151 f ƒ 7 q — k c 0 � 7 \ / _� w' O co < n E q . E § � _ o . ]• CA " 2 § ri \ 0 �� 3 - � ' \ 7ƒ N � � § 0 n ¢ . O k § \, _. En n Q n 0 § ® ? §' 0 fl IV �' 6 A . d . § §. §. q \ \ g \ / R 8 . w• ° 7 - G o p § 1 . ' kk k ® i ) & °• ° 51 \ \ 7 •i• , • `,• • • • ,:cjON ( / 7 -Z i< U 7 S) 7--(— &-97CtP66 0/ 7 � o /c13 •