The URL can be used to link to this page

RES 2012-1084 - Appoint Chad H Gumbert manager of Old Chicago (withdrawn) of�HE srA.TA,4, STATE OF NEBRASKA `Q 4rl�,. -- M�1; C E I V E D is NEBRASKA LIQUOR CONTROL COMMISSION Dave Heineman Hobert B. Rue •=, Governor Rope 12 J 1L1$ 1,� �9 �'�-- A►� 9: 45 Executive Director ,1126.1. 301 Centennial Mall South, 5th Floor P.O.Box 95046 CITY C L E-R K Lincoln,Nebraska 68509-5046 Phone(402)471-2571 July 13, 2012 OMAHA, NEBRASKA 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 OMAHA NE 68183 RE: Old Chicago LICENSE #I-46467 Dear Clerk: Enclosed is a copy of a manager application for Chad Gumbert 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, gazihazziivjgejsulai 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 4;24g^ Buster Brown City Clerk BJB:clj is 4 Z�1 Z ' by �r l l c • Co ice -X Qd date name of person acknowledged Affix Seal _.......,g, otary Pu lic signature „11 �Y +State o!Nebraska JOHN BELL, 1 My COMM.Fes.Aug.S,2015 I b" na ,gd at1 a "_+_' a> kl abo l dl�u'al�wlderst ndt+rt�i „y. h ak`ail f re spo ie r i a• e ti 2;'if �. ,146.-r. ig 7.iy. 5 r. s'''�b k[;'�'7 c . k ;“,,a, .� �. t 1 pl ' v3;th &� di on t-so t gyres if to ete xrl�ul' ` e rat 4 " 5�. ��` .Y`� ,�, that the ,tn � h� cif (�' l��r">��)the 1% e,h`ti t .Arise•;.;57.,. ..+ rf ^ q ... '',.. 4 TCL5O r O 0-6 1) 1 attire of individual involved with application Printed name of applying individual Spouse of individual listed above) State of /'e- u-s Kf. County of N,J,L.5 The foregoing instrument was acknowledged before me this 1 ?A)t C by sa'-- CoGkele 4 name of person acknowledged • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - ,.� MANAGER APPLICATION office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH JUN 2 9 2012 PO BOX 95046 NEBRASKA LIQUOR LINCOLN,NE 68509-5046 ��OL COMMISSION PHONE: (402)471-2571 FAX: (402)471-2814 Website:www.lcc.ne.gov R 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 i + r . ins.; _... R $ L c� : A r,:4- AC-- 4;*A'q*r Name of Corporation/LLC:Wadsworth Old Chicago, Inc. 4 a ye$ j �'"" Jk a 'Y r' 3 F ? a4 A� .' - n r fig _ t t�t9l 1 e. x ititj �.a `�'+r .'c _ se w= b � �. ' 'S h�iF.'" �. ' '> "c"c 'i. s4:'*.1 �" ' ';>a'kwZt'+'44-r ;' , , :r Premise License Number: ' �' (if new application leave blank) Premise Trade Name/DBA:Old Chicago Premise Street Address:1109-11 Hamey St City:Omaha State:NE Zip Code:68102 Premise Phone Number:402-341-1616 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/lics chi / / C,eL 4' e t j f�'lOw 1 CORPORATE E AGING MEMBER SIGNATURE (Faxed signatures are acceptable) RECEIVED 1 11 i_ Form 103 ev 11/2012 JUL0 i 13 201200 Page 2of5 1200013231 NEBRASKA LIQUOR —' — _ — CONTROL COMMISSION attire of individual involved with application Printed name of applying individual Spouse of individual listed above) State of /'e- u-s Kf. County of N,J,L.5 The foregoing instrument was acknowledged before me this 1 ?A)t C by sa'-- CoGkele 4 name of person acknowledged • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - �v J • a I �'t sae V. a: r• ''- '' n 1 �;� II 1� F'{li ' �e t •y I x .�� I 7 ;; � s pT ?'vc J s.,a `vd �;;�-".a 'C:A --3).; �,«,r. k,. �E .y haw a a 9 �r �H It ' . f. fSf�:.�?> nd� "�` vj��' �x-�..si�..� ��,a;�i^a u�`�2�:tab�li�' f� -�t-t�!.hi�...:*�'u Ft gh Gender: ®MALE ()FEMALE Last Name:Gumbert First Name:Chad MI: Home Address(include PO Box if applicable):5208 S 80th Street City:Omaha County: Douglas Zip Code:68127 Home Phone Number:402-547-8989 Business Phone Number:402-341-1616 Social Security Number; -- - Drivers License Number&State: l•N E Date Of Birth: -— -- - Place Of Birth:Omaha, NE voitakt.•C .ffi j Vr r a f^Y �y,n _Y '" tt P. m� 1V; t i f 4 f " r - £ S a ,! rl �� a`�`'., A'�� .t- rc is �� r�.i { � exa � :» �'� r 4.. �:J• �..1,r�a• ..i�i'�.anar._'_ A,,, ,,:.G(k� 1. 6+,�,j�`,<,<,,.h�.. T��x �. � ar»..c - -€„�,., e .5v� C ® ®NO JUL 13 2012 EBRASKA LIQUOR �fr�E}�t.�i �5 �fl la ��sf �.k ``•• '1' 'i�i' Iry t�.�.�ra �� '�9 F.a�83 . y. r, .: � �t �, �irw � .. 1;6 PH � �[(y{�� ge{� 9 �11 V� l f '2w+ ,,yy�� / ,{.." aL € '..s O; . N�,..:c 3.,.... �i.'r a- q lfc '� Lt 6, Spouses Last Name: First Name: MI: Social Security Number: Drivers license Number&State: Date Of Birth: Place Of Birth: 1,;4e3F� ,ud i 4:F � �a' F� j _ �, t�n`��i .,r �'..7 c, a 8 f'r � 'f �'L'�k },u E_is -t d�dR oaf s ` .kl s� z N4WO _S } 41ri i; a k.' �E p'4% h. ,.r' Pi : £q "`'"y"x +-�rr .,F v,a x ,4 } �;...� y ?w+ .?-d Er, �-4 a`�'' �ai�� _w CITY &STATE YEAR YEAR CITY &STATE YEAR YEAR FROM TO FROM TO 206 Railroad Dr, Forest City, NE 2002 2006 11221 Seward Plaza, Omaha, NE 2006 2008 5208 S 80th St., Omaha, NE 2008 Present RECEIVED Form 103 JUN 2 9 2012 Rev 11/2012 Page 3 of 5 NEBRASKA LIQUOR CON-Ton (OMMISSIpN ?A)t C by sa'-- CoGkele 4 name of person acknowledged • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - '4 sa l' - i t �fnEl�r.- iai�I _„x c„ACE-, q t ivt w F +,R.�4 IS LAST 177h '.. s tE �'� s' lb ,4,A sffi�` y d 4; YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 2005 2007 Larson Management Group Austin Johnson 715-215-0746 2003 2005 Fatz Cafe Kelly Land 828-289-0427 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 0c arges by each individu 's name. X YES NO 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) Chad Gumbert 6/2011 Omaha, NE DUI 3rd Guilty Chad Gumbert Dec 2010 Omaha, NE DUI 2nd Guilty ,� ��,, Chad Gumbert Feb 2005 Omaha, NE DUI 1st Guilty 6 Cigai Ct x f sow orruk l�v egi', t, 2. Haveyou oryour spouse ever •een a roved r made application P pp pp on for a liquor license in Nebraska or any other state? CQ ' 0TO IF YES,list the name of the premise. Manager-Old Chicago, 13110 Birch Dr., Omaha, NE 68102 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? gt/FS OTO 4. Have you enclosed the required fingerprint cards and PROPER FEES with this application? heck or monsy order made payable to the Nebraska State Patrol for$038.00 per person) 04°V Ity-rpn‘A-k- ( ,Lt.-cic On cr I C._ 5. List any alcohol related training and/or experience(when and where). ServSafe Alcohol Classes Omaha, NE RECEIVED RECEIVED Form 103 Rev 11/2012 JUL 13 2012 JUN 29 2012 Page 4 of 5 ICq U NEBRASI(A LIQUOR CONTROLNEBRAS COIUdIVl LIQ1SS1ON®R CONTROL COMMISSION d • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - • 4 . s`� +� ��y �t � " � ,' ��t •W �'� e 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/f/t&r), $-)fr;— Signature of Manager Applicant Signature of Spouse / `I ' _, ACKNOWLEDGEMENT WU0 / State of County of ra%. L d(L C-r_ The foregoing instrument was acknowledged before me this 2v1 Z by C/hC4j1 &ttY1 he r&- ate name of person acknowledged ./J1(01,1(A,(11 2W1 AA) Affix Seal Notary Public signature STEPHANI F L DEVINE NOTAR' °UBUC STATE Of COLORADO 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 RECEIVED JUL 13 2012 JUN 2 9 2012 Form 103 NEBRASKA LIQUOR NEBRASKA LIQUOR Rev 11/2012 Page 5 of 5 CONTROL COMMISSION CONTROL COMMISSION l Classes Omaha, NE RECEIVED RECEIVED Form 103 Rev 11/2012 JUL 13 2012 JUN 29 2012 Page 4 of 5 ICq U NEBRASI(A LIQUOR CONTROLNEBRAS COIUdIVl LIQ1SS1ON®R CONTROL COMMISSION d • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - • City ® Omaha fAfebras&a . fir.fr� -Mire"lky;ftz M121819 Farnam —Suite LC 1 sTr 11 Omaha, Nebraska 68183-0112 �o ..`:. '�' *, Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 4 .1 D F�BR�� July 31, 2012 Wadsworth Old Chicago, Inc. Application to appoint Chad H. Gumbert Dba"Old Chicago" manager of your present Class "I" Liquor 1109-11 Harney Street License location Omaha, NE 68102 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 August 14, 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, e;dLe Buster Brown City Clerk BJB:clj f/t&r), $-)fr;— Signature of Manager Applicant Signature of Spouse / `I ' _, ACKNOWLEDGEMENT WU0 / State of County of ra%. L d(L C-r_ The foregoing instrument was acknowledged before me this 2v1 Z by C/hC4j1 &ttY1 he r&- ate name of person acknowledged ./J1(01,1(A,(11 2W1 AA) Affix Seal Notary Public signature STEPHANI F L DEVINE NOTAR' °UBUC STATE Of COLORADO 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 RECEIVED JUL 13 2012 JUN 2 9 2012 Form 103 NEBRASKA LIQUOR NEBRASKA LIQUOR Rev 11/2012 Page 5 of 5 CONTROL COMMISSION CONTROL COMMISSION l Classes Omaha, NE RECEIVED RECEIVED Form 103 Rev 11/2012 JUL 13 2012 JUN 29 2012 Page 4 of 5 ICq U NEBRASI(A LIQUOR CONTROLNEBRAS COIUdIVl LIQ1SS1ON®R CONTROL COMMISSION d • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - City ® ' mania J\febras&a � - tier ( r r �r I 1819 Farnam—Suite LC 1 � �, Omaha, Nebraska 68183-0112 =a,a ' �' Buster Brown (402) 444-5550 iO ti, City Clerk FAX (402) 444-5263 oR'� ® 1FEB�� 44 July 31, 2012 Chad H. Gumbert Application to be appointed manager of the 5208 South 80th Street present Class "I" Liquor License location Omaha,NE 68127 for Wadsworth Old Chicago, Inc., dba"Old Chicago", 1109-11 Harney 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 August 14, 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, Aez" Buster Brown City Clerk BJB:clj f Spouse / `I ' _, ACKNOWLEDGEMENT WU0 / State of County of ra%. L d(L C-r_ The foregoing instrument was acknowledged before me this 2v1 Z by C/hC4j1 &ttY1 he r&- ate name of person acknowledged ./J1(01,1(A,(11 2W1 AA) Affix Seal Notary Public signature STEPHANI F L DEVINE NOTAR' °UBUC STATE Of COLORADO 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 RECEIVED JUL 13 2012 JUN 2 9 2012 Form 103 NEBRASKA LIQUOR NEBRASKA LIQUOR Rev 11/2012 Page 5 of 5 CONTROL COMMISSION CONTROL COMMISSION l Classes Omaha, NE RECEIVED RECEIVED Form 103 Rev 11/2012 JUL 13 2012 JUN 29 2012 Page 4 of 5 ICq U NEBRASI(A LIQUOR CONTROLNEBRAS COIUdIVl LIQ1SS1ON®R CONTROL COMMISSION d • Affix Seal 6Etl8Ml VOTARY-State of kings c signature .aom BELL • I My Came.E,Aug.3,2018 In co Hance 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 35-4178 Revised 1/2008.. - • L . ' 9 " B \ n . k @ k \ 7 7 Q g . . \L IVi 06- % i . K n Q . § \ A q K 1 @.? c 8 E q ° ` ~\ 2 o i - 0 ;' 7 `• ® 5 -, o % i \,_ 0 q % ' n 7 ` . q 7 7 7 6 [ ? • n q R % . • e _ . J-t- FD- t:Ci 17: C:1•• 2 ► ¥ c § `. . iiI O g » 7 . O , .