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RES 2012-1646 - Appoint Jennifer S Toft manager of Old Chicago i o. RECEIVED STATE OF NEBRASKA 7/4. Dave Heineman (2 NO # NEBRASKA LIQUOR CONTROL COMMISSION `1 7 Governor (� Pff�, g Hobert B. Rupe y1 Executive Director ..,.r, r` 301 Centennial Mall South,5th Floor C J T Y EL " P.O.Box 95046 Q M N C t K Lincoln,Nebraska 68509-5046 ✓3 t? s}� ,. Phone(402)471-2571 November 19, 2012 Fax(402)471-2814 or(402)471-2374 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK 1819 FARNAM STREET LC-1 50 /y y OMAHA NE 68183 RE: Old Chicago LICENSE #I-046093 Dear Clerk: Enclosed is a copy of a manager application for Jennifer Toft in connection with Old Chicago 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, i. drDU,cnqaig..> R4-121-1A11/7, Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSIO.N 402-471-2572 encl. • Janice M.Wiebusch Robert Batt William F.Austin Commissioner Chairman Commissioner An Equal OpportunitIVAffirmotiue Action Employer Printed with soy ink on recycled paper l MANAGER APPLICATION Office uxe R ` O E INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION NOV 7 2012 301 CENTENNIAL MALL SOUTH NEBtimbht4 LIQUOR PO BOX 9 NE 68509-5046 LINCOLN,NE CONTROL CO J SSION PHONE: (402)471-2571 FAX: (402)471-2814 Website:www.lcc.ne.gav o7R 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 Corporation/LLC information Name of Corporation/LLC:Wadsworth Old Chicago, Inc. Premise information Premise License Number: -46093, (if new application leave blank) Premise Trade Name/DBA:Old Chicago Premise Street Address:2643 S 144th City:Omaha State:NE Zip Code:68144 Premise Phone Number:(402)330-9001 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.cei dam",,,'___.''_. CORPORATE OFFICER/ iprl7�LGING EMBER SIGNATURE (Faxed signatures are acceptable) Form 103 ley 11/2012 Page 2of5 11111111111 1200021598 ,Tanager's information must be'completed below PLEASE PRINT CLEARLY Gender: ®MALE @FEMALE Last Name: v T First Name: J e MI: Home Address(include PO Box if applicable): aS03 N • 'I% • City: 0 Ma VI A County: O Zip Code: (p 4-' )O Home Phone Number( ,i)' q I—c 1 S 7 Business Phone Number: (1-1O Z) 3 -100 I Social Security Number: Drivers License Number&State: NE Date Of Birth. _ _, • . , Place Of Birth: t-t a't)l S ON WIL rre you married? if yes,complete spouse's information(Even if n spousal affidavit has been submitted) YES ©NO Spouse's information t _�_- _-.. _ _ _ _ - _- Spouses Last Name: —TO FT First Name: MI: E. Social Security Number: _ _ _ _Drivers License Number&State: is _. - 4' Date Of Birth: Place Of Birth: ftirta �•— rAFPL'1CANT&SP5USE LIST RESIDENC:E(5)FOR THE PAST TEN (10)YEARS APPLICANT SPOItSE CITY &STATE YEAR YEAR CITY &STATE YEAR YEAR FROM TO FROM TO ast5ti1I �R NF ln�51t0ti XVOi ROOS C2rM114. Nr (05l10� 9"5 Ala 9l' 1c05otwkigt RECEIVED Form 103 Rev I I/2012 NOV 7 2012Page 3of5 NEBtittbr1N L.IUUOR CONTROL COMMISSION 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.cei dam",,,'___.''_. CORPORATE OFFICER/ iprl7�LGING EMBER SIGNATURE (Faxed signatures are acceptable) Form 103 ley 11/2012 Page 2of5 11111111111 1200021598 4. � :e"ed'l�,w. `'�� ltlitt^ > t,"1^ .J i_ 1, ...'ti' ,r- n,:;:.' s.�.'..� .f wC MV '-.''I lo .'�ZQ ..: .1-i YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER • 004 AC:ia OLb'Oil U4610 S(01T AI0oeE._ Li food A6014 5WrGkelT1 14 GieK5 --mem civo *J (-toN) 9t -117 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 Iaw;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 0c arges by each individual's name. YES 0 NO I yes,please explain below or attach a separate page. Name of Applicant Date of Where Description of Charge Disposition Conviction Convicted (mm/yyyy) (city&state) \R Alit(-CI( 7 lti'to (1 Mthoi I Nt bul. 1\ft:1 bttiM 0(fin ( erd-t6 if C O ; aY WW1q 14, tt4 tv,56),M . 2. Have you or your spouse ever keen approved r made application for a liquor license in Nebraska or any other state? t9YFS UNO IF YES, list the name of the premise. Oats dice „a Actf.3;.1,414`0Cf"• Cig1,1LI , 3. Do you,as a manager,qualify under Nebraska Liquor Control Act(§53-13 01)and do you intend to supervise,in person,the management of the business? Y'ES t TO 4. Have you enclosed the required fingerprint cards and PROPER FEES with this application? heck or mone order made payable to the Nebraska State Patrol for$38.00 per person) FS100 5. List any alcohol related training and/or experience(when and where). Y't Saco Nil(6101 CO-ifctatW k i'tl 50 k o4)Clibe 1 Ce t`f i eel RECEIVED Form 103 Rev 11/2012 Page 4 of 5 NOVA ty 2012 NE8 IM J utaUOR CONTROL COMMISSION 1 PERSONAL OATH AND CONSENT OF INVESTIGATION 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 Tit. 1(744.4.7S Sign re of ana er Applicant Signat a <7Spouse ACKNOWLEDGEMENT State of Nebraska County of ')( t )7i. 16 • The foregoing instrument was acknowledged before me this • 5 H1 oc !n(v ovec iL by jec - cer 5, 1&' t & _ D°Nid Tbil date name of person acknowledged (ItICA Affix Seal aim.NoT✓m o 0f masks N�nia .F uhiicsignaturc �' KYLE A.pBPtERt' My Comm.to.Lba.atfl S 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. W ED NOV 7 2U12 NEBttfi;tu. LtUUOR CONTROLCOMN11B�1�� corm 103 Rev Ilrzolz Page S of 5 I NE8 IM J utaUOR CONTROL COMMISSION • E Print Form SPOUSAL AFFIDAVIT OF q ;Ce us. RECEIV` NON PARTICIPATION INSERT NOV 7 2Oi NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH d�� � fit,a x„ PO BOX 95046 h rfF,�. a(r _ ir'4 4,,.t../JCIFI LINCOLN,NE 68509.5046 CONT OIt. CO j PHONE:(402)471-2571 'e r'/ 1L{ (f� 7\4 FAX:(402)471-2814 Wcbsite: wwwlcc.re.tzcv 4 acknowledge (hail am the spouse of a liquor license holder.~My signature below confirms that I will have not have any interest,directly or indirectly in the operation or profit of the business(§53-12.5(13))of the Liquor Control Act. I will not tend bar,make sales,serve patrons,stock shelves,write checks,sign invoices or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be 'required;however,I am obligated to sign and disclose any information on ail applications needed to process this application. 4 ng Dc ; d Tof t S gnature of spouse as for waiver Printed name of spouse asking for waiver (Spouse of individual Irsted below) State of Neb r0. Ka n . County of FJ GA) 7 k U ,S The foregoing instrument was acknowledged before me this 5 .1, OF N uJer -°r a_01 •? 4 t a. 1 by date name of person acknowledged t� ' r �j ,,W t Affix Seal GENERAL NOTARY State of Nebraska C/ Notary ublic signature (KYLE A.ROPP2RT My Comm.Exp.Doe.29,2015 • `► 1 I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I arc responsible for compliance with the conditions set out above. If it is determined that the above individual has violated 053-125(13))the Commission may cancel or revoke the liquor license. - - - NJ A • Signature indiv, u involv wi plicat.ion Printed name of applying individual (Spouse of individua listed above) State of i\ihr(3 ,51,ca County of 1 0 U , k, .a$ The foregoing instrument was acknowledged before me this 'J[ tVQ c1 r dole)' by tie r\ i ' .c- S. Ibf dote name of person acknowledged C - .. ! Affix Seal • +' GENERAL NOTARY-State of Nebraska N ry Public signatu KYLE A.REPPERT My Comm.Exp.Dec.29,2015 In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate formal. FORM 35-4178 Revised 1/2008 . . ry, 4, city • mt • ha Webri f 1819 Farnam —Suite LC 1 Omaha, Nebraska 68183-0112 � . Buster r:rown (402) 444-5550 1?' City Clerk • FAX (402) 444-5263 O'�ey�® As- December 4, 2012 Wadsworth Old Chicago, Inc. Application to appoint Jennifer S. Toll. Dba "Old Chicao" manager of your present Class "1" I,iqunr 2643 South 144`' Street License location Omaha, NE 68144 • Dear Liquor License Applicant: This letter is notification that a hearing before the Omaha City Council on your appl i cat ion i r appoint a manager to the liquor license has been set for December 18, 2012 . "i he 1.is Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Don gl as Center, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states. applicant for any type of license shall be personally present in the Council Cli^nibers. 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 o yo r application to the Nebraska Liquor Control Commission. Sincerely yours, ,e4,f5e 4141, Buster Brown City Clerk BJB:clj ledged before me this 5 .1, OF N uJer -°r a_01 •? 4 t a. 1 by date name of person acknowledged t� ' r �j ,,W t Affix Seal GENERAL NOTARY State of Nebraska C/ Notary ublic signature (KYLE A.ROPP2RT My Comm.Exp.Doe.29,2015 • `► 1 I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I arc responsible for compliance with the conditions set out above. If it is determined that the above individual has violated 053-125(13))the Commission may cancel or revoke the liquor license. - - - NJ A • Signature indiv, u involv wi plicat.ion Printed name of applying individual (Spouse of individua listed above) State of i\ihr(3 ,51,ca County of 1 0 U , k, .a$ The foregoing instrument was acknowledged before me this 'J[ tVQ c1 r dole)' by tie r\ i ' .c- S. Ibf dote name of person acknowledged C - .. ! Affix Seal • +' GENERAL NOTARY-State of Nebraska N ry Public signatu KYLE A.REPPERT My Comm.Exp.Dec.29,2015 In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate formal. FORM 35-4178 Revised 1/2008 U ®lam ' Cuy .f • f ; ,,, r , r e a rf s kr ...N. ,,,, ,,„„,,,,,,,,,,,, ,,, ,; , ‘, ,,,,, ., ,.„4,,,, Cr 1819 Farnam—Suite LC 1 ��' /A11( . ' r` Omaha, Nebraska 68183-0112 0n. .:3 ;, .., Buster Brown (402) 444-5550 �05•` ...;', A.�', City Clerk FAX (402) 444-5263 0�'� t®- 'h °-+ 0 • December 4, 2012 • Jennifer S. Toft Application to be appoi n f•."d man aL c r the 2503 North 71St Street present Class "I" Liquor Liccnsc•ioc,ai if,ns Omaha, NE 68104 for Wadsworth Old Chicago. inc.. ci h,, "Old Chicago", 2643 South l-!4''' ;;trcct and 1111 Harney Street Dear Liquor License Manager Applicant: This letter is notification that a hearing before the Omaha City Council on your appli cat i ,n in he appointed manager of the liquor license has been set for December 18, 2012 . The ('i; Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha1Dcuugias Civic Center, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule 1,:. . , states.. "Li,h applicant for any type of license shall be personally present in the Council C;;;.iiaher . in order that the Council may make inquiries, on the date of public hearing of the ai.,;''.ica;i,)n Hr , cl license". Failure to be present at this Council Meeting is grounds to recommend do-n,S ,i r•.I'your application to the Nebraska Liquor Control Commission. • Sincerely yours, ._444°'''16)1e Buster Brown • City Clerk BJB:clj signature (KYLE A.ROPP2RT My Comm.Exp.Doe.29,2015 • `► 1 I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I arc responsible for compliance with the conditions set out above. If it is determined that the above individual has violated 053-125(13))the Commission may cancel or revoke the liquor license. - - - NJ A • Signature indiv, u involv wi plicat.ion Printed name of applying individual (Spouse of individua listed above) State of i\ihr(3 ,51,ca County of 1 0 U , k, .a$ The foregoing instrument was acknowledged before me this 'J[ tVQ c1 r dole)' by tie r\ i ' .c- S. Ibf dote name of person acknowledged C - .. ! Affix Seal • +' GENERAL NOTARY-State of Nebraska N ry Public signatu KYLE A.REPPERT My Comm.Exp.Dec.29,2015 In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities. A ten day advance period is requested in writing to produce the alternate formal. FORM 35-4178 Revised 1/2008 e bN )O*, N OZ • CD ru cii,-, PO Po 0 CD n 00 "r,. Cl)- N • �' -.crop) 0 CD CL, O 00 C7 u o rn n co Po -P' O O • a � w E. ® -• N,