RES 2012-1139 - Appoint Teresa L Simplot maanger of Hampton Inn & Suites Omaha Downtown i
RCEI
ATE OF NEBRASKA
1 1,1
d:.
/;1„ .;�•.9 b Vie/ N BRa�i�C J? OR CONTROL COMMISSION
Dave Heineman �j 7• I D
� _ 12 aLIG I Hobert B. Ru e
Governor t
h� � � Executive Director
'R Deb^ 301 Centennial Mall South,5th Floor
CITY CLERK P.O.Box 95046
OMAHA, NEBRASKA. Lincoln,Nebka 68509-5046
Phoneras(402)471-2571
August 3, 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
OMAHA NE 68183 •
RE: Hampton Inn & Suites
LICENSE #C-078365
Dear Clerk:
Enclosed is a copy of a manager application for Teresa Simplot in connection with the Hampton Inn &
Suites Omaha Downtown 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,
qa.dret..iyi-4-ct-ur_ey,/
•
Jacqueline Rodriguez
G 9
Licensing Division
NEBRASKA LIQUOR CONTROL COMMISSION ':
402-471-2572 -
encl.
Janice M.Wiebusch Robert Batt William F.Austin
Commissioner Chairman Commissioner
An Equal Opportunity/Afirmatiue Action Employer
Printed with soy ink on recycled paper
Brown
City Clerk
BJB:clj
se AUG 3 2012
1 NEBRASKA LIQUOR
CONTROL COMMISSION
ACKNOWLEDGEMENT
State of Ne
County of The foregoing instrument was acknowledged before me this
?7 2017 by yoc1
date name c�`en admewtedged
Aar seat
Notary Public signature _ GENERAL NOTARY-State of Nebraska1 I, SARA SCHRODER
' My Comm Exp.dmw 15,2016
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. •
Nam 103
Rev 11/2012
Pie 5 of5
rol for$38.00 per person)
ES Ii0
5. List any alcohol related training and/or experience(when and where).
Form 103
Rev 11/2012
Pawl ofS
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CITY SsSTATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO PROM TO
14� ivI .D07 T
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Form 103
Roy 111101$
papa arc
• 0713012012 10:50 fA) P.003/003
MANAGER,APPLICATION woe tin
INSERT-FORM 3e .EIVED
N B ASICA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH AUG 3 2012
PO BOX 95046
LINCOLN,NE 68509-5046 NEBRASKA LIQUOR
PHONE: (402)4714571 CONTROL COMMISSION
FAx:(402)471-2814
Wobsite:www,1cc.s a gpx
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 followfmg: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 S38
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
Name of Corporation LC: OPYthe Nntt-1)&47WYL Laat rtt5Jdv V Lit
.'se higizmatien
Promise License Number: C glot4
(if w applio on leave blank,
Premise Trade:Name/DB►A: - (, � Y �x 1,4,4 f'-CS
Promise Street Address: /4Rg (. .,SYeePel
City: , ,�,, _ State: Zip Code: aer/0
Premise Phone Number: 410g 6,5061 _--------_
The individual whose name is Iisted 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 individ
uals,
als.
hitoghvvyf.lce,nzgpvtlicense sse,reh icsearcb.cJ
• CORPORATE OFFICER/MANA g i c ,ra1►: :i• SIGNATURE
(Faxed signatures : = acceptable)
Forst 103
atoll/2012
II II II
Page Z of.s.
1200014408
his application is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format. •
Nam 103
Rev 11/2012
Pie 5 of5
rol for$38.00 per person)
ES Ii0
5. List any alcohol related training and/or experience(when and where).
Form 103
Rev 11/2012
Pawl ofS
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CITY SsSTATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO PROM TO
14� ivI .D07 T
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Form 103
Roy 111101$
papa arc
• 0.713012012 13:31 (FAIO P.0021004
RECEIVED
M'apagee.sInfo ration MusetteconipJj blow P BPANT • 'Y'• 9t 'rr,;
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Gender: B ' ASKA LIQUOR
FB�i�lLB (��:"''
Last Name: IwapIo - First Name: JINTROLCOMMJON
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Rome Address(include PO Box ifappfiesbto): j1 LO- a_I(4 i 4,.
Ctt - County: D.bttl!a c. .zip COde:_leill
Home Phone Number 6 j—..6�C ( Business Pbmtie Number: Loa- 5 16"5/ob
SoaIai Security Number:r _ • - , Drivers License Number&State. 1V•!
Dete Of Birth:_ Pimp Of Birth;TPA236AelJ tJ�-
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Spouses Last Name: — FIrs(14 m ;
Social Security Number: ,Drivers License Number&State:
Date Of Birth: Place Of Btrt3_
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YEAR NAME OF EMPLOYER NAME OF SUPS `�`s;i r' f a, t1 n„i 1�1 q�A.
FROM TO ®N
AV/ 10Py jthemiti %� 515 -77/-�6ylf7
zY° I Wes 140 2-3vs-56'
I. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed
by both applicant and spouse,unless spouse has Wed 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
c,•rges by each individual's name.
,,- . YES NO
,es,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)
SL - n ` Woved lcQ,+C6rlv04tcafe - /�
� - �� / l r3l l3� 5k 0¢4 go Acc b 1'Lnp_.
rieganotst
2. Have you or your spouse ever been approv • made application for a liquor license in Nebraska or
any other state? OYES �r4 O
IF YES,list the name of the premise.
3. Do you,as a manager,qualify under Nebraska Liquor Con( •1,• ct(03-1 31 01)and do you intend to
supervise,in person,the management of the business? d4, ES 040
4. Have you enclosed the required fingerprint cards and PROPER FEES with this application?
eck or mone order made payable to the Nebraska State Patrol for$38.00 per person)
fr4ES 0
5. List any alcohol related training and/or experience(when and where).
Form 103
Rev 11/2012
Page 4 of S
,Drivers License Number&State:
Date Of Birth: Place Of Btrt3_
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•
. 07/30/2012 1322 f P.0041004
.H • ,3-�f T O�"''S;'�•T"a` N } i� } �1i. '' AIL' .
The above individual(a), being first duly sworn upon oath, deposes and states that the undersigned b the
applicant and/or spouse of applicant who makes the above end fbrogoing application that said applicatbnhas
been read and that the contents thereof and all statements retain ed therein are rate. Ifany rise 8tateam at is
made in any part of this application, the appitcant(s) shall to deemed guilty of perjury and subject to
penalties provided by late. (Sec§33-131.01)Nebraska LiquorControl Aot. .
The undersigned applicant hereby consents to an lnveatigation ofhls/ker background including all records of
every kind end description including.pollee records, tax records (State and Federal), and bank or lending.
institution records,and said appl leant end spouse waive at rights or uses of anthill that said applicant or
spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or
releasing said lntbnnadon to the Nebraska Liquor Control Commission. Vaporise hes 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 thetlntbrmatian submhted In
this aappllIc anion, is*sub,jeot to cancellation if the Information contained herein is.incomplete, inaaau rate,or
t�`audulent.
J14-&-441 .44 • /
Signature of Munger Appl1..:.'t Signature of 8 rU E i
AUG 3 2012
AC:WOwiaoos T • NEBRASKA LIQUOR
State of CONTROL COMMISSION
County olcimatymokirt., The Ibrugoing betnrment was aciaoowledged Wive roe this
i V.02 ._..� by
/
.;.� sae
t9nna SCHRODER
turn.= dma th
In compliance with the ADA,this application is available in other limmets for persons with disabilities.
A ten day advance period is required in writing to produce the alternae farmat.
Palm Im
a,.t 1f7o1S
4 of S
,Drivers License Number&State:
Date Of Birth: Place Of Btrt3_
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City of Omaha, Nebraska 0 ilk ,
!�jrC,�
F — 2 Wirt
t ` t,
1819 arnam Suite LC 1 �®z rr ills z
Omaha, Nebraska 68183-0112 0 � �,
Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263 o'4TFo FEBRI-
August 14, 2012
Omaha Downtown Lodging Investors IV, LLC Application to appoint Teresa L. Simplot
Dba"Hampton Inn and Suites Omaha Downtown" manager of your present Class "C" Liquor
1212 Cuming 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 28, 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
s.incomplete, inaaau rate,or
t�`audulent.
J14-&-441 .44 • /
Signature of Munger Appl1..:.'t Signature of 8 rU E i
AUG 3 2012
AC:WOwiaoos T • NEBRASKA LIQUOR
State of CONTROL COMMISSION
County olcimatymokirt., The Ibrugoing betnrment was aciaoowledged Wive roe this
i V.02 ._..� by
/
.;.� sae
t9nna SCHRODER
turn.= dma th
In compliance with the ADA,this application is available in other limmets for persons with disabilities.
A ten day advance period is required in writing to produce the alternae farmat.
Palm Im
a,.t 1f7o1S
4 of S
,Drivers License Number&State:
Date Of Birth: Place Of Btrt3_
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• CityofOmaha Webras&a 4*fr
s�
114.1114.11
1819 Farnam—Suite LC 1 z vic
co
Omaha, Nebraska 68183-0112 0
Buster Brown (402) 444-5550 A �,
City Clerk FAX (402) 444-5263 oR4T�D FEB
August 14, 2012
Teresa L. Simplot Application to be appointed manager of the
1110 North 49th Avenue present Class "C" Liquor License location
Omaha,NE 68132 for Omaha Downtown Lodging Investors
IV, LLC, dba"Homewood Suites Omaha
Downtown", 1212 Cuming 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 28, 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
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Signature of Munger Appl1..:.'t Signature of 8 rU E i
AUG 3 2012
AC:WOwiaoos T • NEBRASKA LIQUOR
State of CONTROL COMMISSION
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In compliance with the ADA,this application is available in other limmets for persons with disabilities.
A ten day advance period is required in writing to produce the alternae farmat.
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