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RES 2012-1290 - Appoint Gregory A Petersen manager of American Legion 374 ST,9phhp STATE OF NEBRASKA halt- RECEIVED 4,1,';le=7�`�ut �;^rn NEBRASKA LIQUOR CONTROL COMMISSION ,,.� �� ,,�; ,�s Dave Heineman �2 r r i r... ''= Governor SE P �'4 n 8: 5`3 Hobert B. Rupe 11. Executive Director ttt y9R`'i' 86^F _ 301 Centennial Mall South,5th Floor CITY CLERK P.O.Box 95046 Pq A F R CJ I Lincoln,Nebraska 68509-5046 Phone(402)471-2571 August 31, 2012 Fax(402)471-2814 or(402)471-2374 g 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: American Legion 374 LICENSE #C-001255 Dear Clerk: Enclosed is a copy of a manager application for Gregory Petersen in connection with the American Legion Post 374 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, 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 MANAGER APPLICATION office use INSERT-FORM 3c F?ECEfVE NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH Or •0 1 1 Q17 PO BOX 95046 LINCOLN,NE 68509-5046 C NEBRASk4 L! PHONE: (402)471-2571 nl nM wog FAX: (402)471-2814 -1019 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$38 per person,made payable to Nebraska State Patrol 5) Must be 21 years of age or older 6) Maybe required to take a training course • t }}0�*** ° ` � aN 0 3 = � rT hk! S ,, a a•f..fi'fla yi �flK v. • > 4A i . i ; .iva 44 c ) • ,1 ,if• -.f' 3�, ,x ..� ,w ..a_ .f-....• •td.14 .�1.�'r` '1tr.V�+P.S%/Ja4AL'�'R.... q.bSt. 1Y_ Name of Corporation/LLCNnerican Legion 374 _ 4 .,. '/ bi ,' • q. d MV <,��.: >:�F 'dFiv F t'-t+f` 'f. '4 / ✓ S G } 'j 'X .. AH4 'SAP '� ';',4A ju `¢`t7. rxi is r Premise License Number., 2 5 (if new application leave blank) Premise Trade Name/DBAAmerican Legion 374 Premise Street Address13913/15 S Plz Cit)Omaha _State:NE Zip Code: 68137 Premise Phone Number402 895 1324 The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals. httn://wwwlcc.ne.eov/license search/licsearch.cei O ORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) 111111111 1200016744 ' "k t 4,r* J Map e','� I it. f "ten ii.Ay .t � - } v iti WA, ��,yx i J`P,� �V 'a1S ^ i'+ �l yw .v J yf'37. b at d ,T NXS _ 3 + n t... �`... N J,,', '''Mvg``f+ti a 68 4 N I '��iy��,r�,w N✓n � o. " Y a 1 �e . Ai V X.�'t,i 4.may u�v,t f a p�� k k, ,, 2S�4a'1'�"":4��si� �:.,�s'i�`"cV��.+�y,,,i.�.,A, °^'I a....�.l �c �'x �$ '" Zits N 4 rn. ��r� { d) Gender: MALE FEMALE Pe - rsen Gregory A Last Name: 138 ' ci r MI: Horn Ad (include PO Box if applicable): Omaha Douglas 68137 City: County: Zi Code: 402 894 2949 402 895 1324 Home Phone Number. Business Phone Number: NE _ Social Security Number. Drivers License Number&State: _ Amerillo, Texas Date Of Birth: Place Of Birth: Aii'`' 'le v ^'i^r '."rf'� �a+e v '7�'RH�a*,+Yv'`� "'T. t�y5� '� j r lA6a &�?::' ; ro �ma ed`r fty Oom" :e—66 s 11 iiirition ven if Zi a# 2Y r , $ 0 '.� r �' 'na?'n M �'? e+S; r :' k'.k t `a.'�A i,,,,§ a w r +p a ,A, 4,,.a.. r " .+,, r I � �r' 1:! ag'S; �� 's`� )) vd' v "1� t kr aas 1�,a .a, eg d x M lg yP,.H, y;> Fl M Jan ,K,a ux .t!r�i[t7+ ''k: ta(r�a �rtr°,iy"� r..f��d .�,V,� c.:;.� . ��.f.v�7�ipvA;,�1,.X3 9+�s9k ....��rCz 4�. �t�'•7e%+a"�.° 'ls,�rn.. ti,��s� O'A YES 0 NO '"l0 312012 coNeliYiat „ xe� '}' , ro s si' u�., & v , 1 t r s r n M r �"..*• v ��y lS y.', Cv"2 Y P`},'p 6 4 q' �. 1�i ("�'M Y 3S :1 Ph. t J w +'"'" :, ..'� 7 b :ak`'G' t d . 3'Iv;S"sry ;lk'FV*a;4.;; > .r ..tw�.aua.� ;? �,,a,,;fr.�ti6,✓..S..i,,.�'i..�.rix.`r.u.a,' s� ISd+%r `ma',�.. ."• .. oS�';, .. ^� '3 :.,•�' �; , Spouses Last First Name: Lisa MI: L Social Security Number. Drivers License Number&State: NE Date Of Birth:- - - - Place Of Birth: Creighton, NE 4I A , 04tLI x R� NCEO FOR }:�sT xo , r4944 i n 4 `;,, f. hu �,8 r r d^ ^4. p y y, r 4 W s ,V S I V a'�9 !. x 7 3 I$ + V ,01 ,t hF a :� '�� Vk 6 w ;.,, r *s .��9' f.#� + .N '� r x r._ '.io 'ti `t' r 1,2' kar "v J.,Ar . `$ - 1. V X, v ,{ 4 t ;•t'i.1 a a 1` ,-,,, l ilig N itao it ° tri a 1;'6- vim,,r, ' 1 ;. r„ . Brous �.((��# Y ,. k'„ e4..`zTty''''' ' `t ; .I.�i11e:w $ ; ; ,�a S,e} ..� �.?7.:b ul� 1;+ B1S10.NF�tLSi�4 CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1994 pres Omaha, Ne 1994 Fenn 103 Rev 11/2012 Page 3of5 ;v ex- wwra�.a a ;mn� ,tY,B--'4 �h, �,"©. ter, :. �G,�P�!�`+zy�Cq�,�ti� �� } ""*�,�-F�� w� ; 'h ri..T i ' �' shag', _,, "'r T Two 1... 7' , „rr }y ' < ;"f+ u 5.. ?:.* r� ry � � v 44 �. pYYEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE 5 pres? AT&T AQIF Malik 8I 448 1999 2005 Carlson Hospitality- William Newman 402 501 5000 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,SEVER 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 : local law, ordinance or resolution. List the nature of the charge,where the charge occurred and the year � ": conviction or plea. Also list any charges pending at the time of this application. If more than one party,please c. x arges by each indivi 's name. Q CIu 3 ten, YES NO 1 c ? If yes,please explain below or attach a separate page. EBRA N C®IUTiZoni Name of Applicant Date of Where Description of Charge Ai!'an, + ` Conviction Convicted l�� (mm/yyyy) (city&state) Greg Petersen 11/2011 Des Moines, IA speeding Fined Paid 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYES 010 IF YES,list the name of the . - a. se. 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? jES rjo 4. 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$38.00 per person) . S gO 5. List any alcohol related training and/or experience(when and where). Bartender- American Legion Post 374 2006-present Form 103 Rev 11/2012 Page 4 of S ghton, NE 4I A , 04tLI x R� NCEO FOR }:�sT xo , r4944 i n 4 `;,, f. hu �,8 r r d^ ^4. p y y, r 4 W s ,V S I V a'�9 !. x 7 3 I$ + V ,01 ,t hF a :� '�� Vk 6 w ;.,, r *s .��9' f.#� + .N '� r x r._ '.io 'ti `t' r 1,2' kar "v J.,Ar . `$ - 1. V X, v ,{ 4 t ;•t'i.1 a a 1` ,-,,, l ilig N itao it ° tri a 1;'6- vim,,r, ' 1 ;. r„ . Brous �.((��# Y ,. k'„ e4..`zTty''''' ' `t ; .I.�i11e:w $ ; ; ,�a S,e} ..� �.?7.:b ul� 1;+ B1S10.NF�tLSi�4 CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1994 pres Omaha, Ne 1994 Fenn 103 Rev 11/2012 Page 3of5 ''41 -s` s q..,r RSON8 001 Np CONSOrt I11I`�V '►TICiATION yYf 1M ' h �., �^ N ,�.'. ` , .'h "AM .n �;-:..:q R ram' 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. a � tit Signature of Maannag Applicant Signature of Sp. CEIVED AUG 3 1 2012 ACKNOWLEDGEMENT NEBRASKA LIQUOR State of Nebraska / (inn I County of .)L)(,( tact Q The foregoing instrument was ackno�w1eaged'° �bac 411 � �Lc4 �at� try Ar Ii oru P.eierrstn and (as&L Peer. date of person acknowledged Oari. Lk Affix Seal Notary Public signature t:> �- Nebtas CARTPUK My Comm.Grp.March 10,2014 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. Form 103 Rev 11/2012 Page 5 of 5 hu �,8 r r d^ ^4. p y y, r 4 W s ,V S I V a'�9 !. x 7 3 I$ + V ,01 ,t hF a :� '�� Vk 6 w ;.,, r *s .��9' f.#� + .N '� r x r._ '.io 'ti `t' r 1,2' kar "v J.,Ar . `$ - 1. V X, v ,{ 4 t ;•t'i.1 a a 1` ,-,,, l ilig N itao it ° tri a 1;'6- vim,,r, ' 1 ;. r„ . Brous �.((��# Y ,. k'„ e4..`zTty''''' ' `t ; .I.�i11e:w $ ; ; ,�a S,e} ..� �.?7.:b ul� 1;+ B1S10.NF�tLSi�4 CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1994 pres Omaha, Ne 1994 Fenn 103 Rev 11/2012 Page 3of5 REC SPOUSAL AFFIDAVIT OF office Use r VL® NON PARTICIPATION INSERT • 0OLLOVLCoVNsslox AUG p I 2�,)31 CENTENNIAL MA SrHPO BOX 95046 LINCOLN,NE 68509-5046 CON RASKA LIQUOR PHONE:(402)471-2571 FAX:(402)471-2814 OC CuMlli'cg10.. Website: www.icc.ne.aov a� sv k ..o k ," = am,theses a of a iquuor lice se o` der. Ivry signature*op w,'confrms that I w�have nothave y �' 4 t is; r iiid ly m e peration or;pr'ofit of the:sbusiness( 53,-14,00:4 )'offthe Liquor Co Act ,I will not i ar, .: ` ',sales,s t , o , shelves,Kvwrite�chetks,4�sign invo1„, ar�3 entwmyseTlf as the ow vner or 1nany eipate ythle day; o ,y. patrons oft?►1s business In any capacity, I understand m+fing rint will not be s' s r ,rY`;i ri 'h f yY•+! yp Stw rpt i� a a I, riI �i �a r , � i '� r ho eycr; um bb11 ,tc sign at d close airy infori a ibpi oil alliapplications needed to'process thhis t h t a L� } a !!} ,4 a ^'�.fi-t,I r 7i l ,iiS4e±�(,'' JY'{t M ern.•w. Ei, r f� . i 7 + a .P�1( ajl.Y1 r ��4*'' !,scs,,a>�,0 41J ul5 k ie J 7'AV,� 'iY:��I Y�"�C. ,iv;,-;9sv aFyYr+C��r�:�� .e. '� 4 ``'f f i�� 3i'. ��? ^+�J'gg ‘44; dP.S). L L PPrER,SE1) Signature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) State of kttioraska County of aulia,s . The foregoing instrument was acknowledged before me this ( l uou I q 2oi� by Loa, P. -ter&en Li` name of person acknowledged j� t plizei Affix Seal earl 1 GENERAL NOTARY-State Nebmsita Notary Public signature 'i CAM PUK 'ri. Conn..,a..March 10,2014 "",""'a<R�Y'+�^y'WT73^ I � y n •v x'et'*'^T'FTTCRr'�� 2r°'m".3r Fx .ld�kY' 4 I Itr1o� e t thb s cI1 a,0 ..,gtCS a indivltlual aua( t tl at y s 3o" se anc r Fug respbntlblb fob t i�' t t.�'�y^W.t w' t' r4 ! r �:;1 qx , t a , i 4 i r tsa t dfi + #� �+, i { `+ aX «�' �,w o 1CG M' h� 4 [tom IianceT the n itions t f: e.;t��If 1 eterminec.thatthe a` ova mtuvidual has', iolated( l l25(13))tie 1 �,�.w,•,Ww',�.�ry��y��r,,,1,,,,`,{5 •��,.1'�1, f r� ; it��' p+'�'.t��,'! (''�G �r r d� �t � i b P t+a I I�''. t +y t � t � ., o? is ion'n1 ': n i r o t e li Yor lice iii :'`s.,e„ Y• Ssx ii:%d�zG a, :?.iii;. #i.i�"rK ys�!Ft*.ii: . *t,'s 3 ,ty ..its- c .8 G6Psoer. A D £TAU£.,-/ Signature of individualinvolved with application Printed name of applying individual (Spouse of individual listed above) State of L.bra /,, County of DO 9 10 The foregoing instrument was acknowledged before me this EWUM 2a �U 12- by 8r o{'U P &'St'1 ,il_.,date of person acknowledged (Ian Affla Seal : GENE.NORRY-51818 of Nebraska PUK Notary Public signature --12: My Comm.E cp,IMarch 10,2014 • 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 format • FORM 354178 Revised 1/2008 City . t ma a fI'lebras&a I 1819 Farnam—Suite LC 1 nl i� � Omaha, Nebraska 681 83-01 1 2 Buster Brown (402) 444-5550 1,4 City Clerk FAX (402) 444-5263 04) 41. 41:e0 FElaRUP4 September 11, 2012 American Legion 374 Application to appoint Gregory A. Petersen 13913-15 "S"Plaza manager of your present Class "C" Liquor Omaha,NE 68137 License location 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 September 25, 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 g ‘44; dP.S). L L PPrER,SE1) Signature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) State of kttioraska County of aulia,s . The foregoing instrument was acknowledged before me this ( l uou I q 2oi� by Loa, P. -ter&en Li` name of person acknowledged j� t plizei Affix Seal earl 1 GENERAL NOTARY-State Nebmsita Notary Public signature 'i CAM PUK 'ri. Conn..,a..March 10,2014 "",""'a<R�Y'+�^y'WT73^ I � y n •v x'et'*'^T'FTTCRr'�� 2r°'m".3r Fx .ld�kY' 4 I Itr1o� e t thb s cI1 a,0 ..,gtCS a indivltlual aua( t tl at y s 3o" se anc r Fug respbntlblb fob t i�' t t.�'�y^W.t w' t' r4 ! r �:;1 qx , t a , i 4 i r tsa t dfi + #� �+, i { `+ aX «�' �,w o 1CG M' h� 4 [tom IianceT the n itions t f: e.;t��If 1 eterminec.thatthe a` ova mtuvidual has', iolated( l l25(13))tie 1 �,�.w,•,Ww',�.�ry��y��r,,,1,,,,`,{5 •��,.1'�1, f r� ; it��' p+'�'.t��,'! (''�G �r r d� �t � i b P t+a I I�''. t +y t � t � ., o? is ion'n1 ': n i r o t e li Yor lice iii :'`s.,e„ Y• Ssx ii:%d�zG a, :?.iii;. #i.i�"rK ys�!Ft*.ii: . *t,'s 3 ,ty ..its- c .8 G6Psoer. A D £TAU£.,-/ Signature of individualinvolved with application Printed name of applying individual (Spouse of individual listed above) State of L.bra /,, County of DO 9 10 The foregoing instrument was acknowledged before me this EWUM 2a �U 12- by 8r o{'U P &'St'1 ,il_.,date of person acknowledged (Ian Affla Seal : GENE.NORRY-51818 of Nebraska PUK Notary Public signature --12: My Comm.E cp,IMarch 10,2014 • 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 format • FORM 354178 Revised 1/2008 City ® ® a Nebraska ` �/ tier rtti 1819 Farnam—Suite LC 1 clreE d Omaha, Nebraska 68183-0112 0 � ow, Buster Brown (402) 444-5550 .o ti, City Clerk FAX (402) 444-5263 �'i) FEBSr.41-� September 11, 2012 Gregory A. Petersen Application to be appointed manager of the 13820 "X" Circle present Class "C"Liquor License location Omaha,NE 68137 for American Legion 374, 13913-15 "S" Plaza 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 September 25, 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, A4 *( Buster Brown City Clerk BJB:clj waiver Printed name of spouse asking for waiver (Spouse of individual listed below) State of kttioraska County of aulia,s . The foregoing instrument was acknowledged before me this ( l uou I q 2oi� by Loa, P. -ter&en Li` name of person acknowledged j� t plizei Affix Seal earl 1 GENERAL NOTARY-State Nebmsita Notary Public signature 'i CAM PUK 'ri. Conn..,a..March 10,2014 "",""'a<R�Y'+�^y'WT73^ I � y n •v x'et'*'^T'FTTCRr'�� 2r°'m".3r Fx .ld�kY' 4 I Itr1o� e t thb s cI1 a,0 ..,gtCS a indivltlual aua( t tl at y s 3o" se anc r Fug respbntlblb fob t i�' t t.�'�y^W.t w' t' r4 ! r �:;1 qx , t a , i 4 i r tsa t dfi + #� �+, i { `+ aX «�' �,w o 1CG M' h� 4 [tom IianceT the n itions t f: e.;t��If 1 eterminec.thatthe a` ova mtuvidual has', iolated( l l25(13))tie 1 �,�.w,•,Ww',�.�ry��y��r,,,1,,,,`,{5 •��,.1'�1, f r� ; it��' p+'�'.t��,'! (''�G �r r d� �t � i b P t+a I I�''. t +y t � t � ., o? is ion'n1 ': n i r o t e li Yor lice iii :'`s.,e„ Y• Ssx ii:%d�zG a, :?.iii;. #i.i�"rK ys�!Ft*.ii: . *t,'s 3 ,ty ..its- c .8 G6Psoer. A D £TAU£.,-/ Signature of individualinvolved with application Printed name of applying individual (Spouse of individual listed above) State of L.bra /,, County of DO 9 10 The foregoing instrument was acknowledged before me this EWUM 2a �U 12- by 8r o{'U P &'St'1 ,il_.,date of person acknowledged (Ian Affla Seal : GENE.NORRY-51818 of Nebraska PUK Notary Public signature --12: My Comm.E cp,IMarch 10,2014 • 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 format • FORM 354178 Revised 1/2008 O N O d t N CD I NO CfQQ ".'�' '�. N �. • O, O J 0 \ C� G7 0 0 ra. La et