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RES 2012-0585 - Appoint Paul J Selvin manager of The Observatory Lounge F ONE`S T9,TA\phi E R EIV c STATE OF NEBRASKA NEBRASKA LIQUOR CONTROL COMMISSION y)�\��!-Via/ Dave Heineman p p , , : _ Governor 12 4! R —6 fti 9 07 Hobert B. Rupe e6°� Executive Director 301 Centennial Mall South, 5th Floor CITY CLERK P.O.Box 95046 Lincoln,Nebraska 68509-5046 C M A I-I A. N E EI R A S K�; Phone(402)471-2571 April 4 Al22 Fax(402)471-2814 or(402)471-2374 p 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: The Observatory Lounge LICENSE #C-73075 • • Dear Clerk: Enclosed is a copy of a manager application for Paul J. Slevin in connection with The Observatory Lounge 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 . • NEBRASKA LIQUOR CONTROL COMMISSION C�'V E® 301 C MALL SOUTH RECEIV PO BOX 95046 MAR 212011 LINCOLN,NE 68509-5046 APR 0 2 2012 PHONE: (402)471-2571 UMW/WINS LIQUOR FAX: (402)471-2814 aEBRASKA �, ,��qgRalsl®�1 Website: www.lcc.ne.gov CONTROL COMA 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 - i. i • !1 Name of Corporation/LLC: T Ai/ J i - Premise information Premise License Number: ..(phew ap gation leave blank) Premise Trade Name/DBA: (bj `1Gi4 �d Premise Street Address: 9 /0 .. . G 7 4,(...._ C;, — City:0Jj.N- State: /Ue". Zip Code: Premise Phone Number. LiO 2' q32.. -0XG 2- 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.go 'cense sear h/licsearch.cgi CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) 1111 Form 103 Iv 11/2012 Page 2 of 5 1200006895 'Manager's information must be completed below PLEASE PRINT CLEARLY • . Gender: O MALE ®FEMALE VPR 12011 Last Name:' e V c First Name: l �. ',1-"11 ®• 44 Home Address(include PO Box if applicable): /tf/ ee' - �� !' t .? City: 0h / County: 0-5 Zip Code: 6?/q /Y Home Phone Number:'2i77 30 %Business Phone Number !)C ` — 22? Social Security Number: _ - Drivers License Number&State: Date Of Birth: Place Of Birth: Di(L , � t Are you married?If yes, complete spouse's information(Even if a spousal affidavit has been submitted) i OYES IDNO Spouse's information 0. Spouses Last Name: First Name: MI: Social Security Number: Drivers License Number&State: Date Of Birth: Place Of Birth: ;APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS • APPLICANT SPOUSE CITY&STA r YEAR YEAR CITY&STATE YEAR YEAR tLZi!` It flit; FROM TO FROM TO , 10f Aseer(-- p) 14,.3 , kir is- a Form 103 Rev 11/2012 Page 3 of 5 remise Street Address: 9 /0 .. . G 7 4,(...._ C;, — City:0Jj.N- State: /Ue". Zip Code: Premise Phone Number. LiO 2' q32.. -0XG 2- 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.go 'cense sear h/licsearch.cgi CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) 1111 Form 103 Iv 11/2012 Page 2 of 5 1200006895 l__._.. •-------- -.------- ._._.._....-_MANAGER'S LAST TWO EMPLOYERS_..----.-------.---.. 1 . YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE • FROM TO , f --� NUMBER 09 PrSIA4 I k) Pabc Vik \\I will gat,Li in lb t 33 / 02-23 / ge g e,)&-Ce-r‘a l'eed 7-1./ N /(te-(If 4 es 2 -Pr-L/9 7-c:-2--ra 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 mom � , conviction or plea. Also list any charges pending at the time of this application. If more than o 5". 'a,,�) .,- ist charges by each individ ' name. �� YES _ NO ,�Oe yes,please explain ow or attach a separate page. MPR '1 00k Name of Applicant Date of Where Description of Char sulk I 5 k-a� Conviction (ty&state) G(��1��®�2. Have you or your spouse ever eyn approved made application for a liquor license in Nebraska or any other state? (JYES O IF YES,list the name of the premise. 3. Do you, as a manager,qualify under Nebraska Liquor ContrI 1 Act(§53-13101)and do you intend to supervise,in person,the management of the business? CIP -S ONTO 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) S' S OW 5. Lis y alcoho`related training and/or experi ce(when and where). /44,.) , /`/�4 . T� h v- edC7 ! 9tae- _c,a kliNg �t, 9e -61efitevF°1r1n/210r2 f�`�' / Page 4 of 5 I-_......__._._.._._... -PERSONAL OATH AND CONSENT OF INVESTIGA:II t}-=_. EV�E�-------, i I III The above indiauoil vidual(s), bei first duly sworn upon oath, deposes and states 4I:;It ;' F 4 ng \I+P: applicant and/or spouse of applicant who makes the above and foregoing applicants•Rn I�,,v.'d�a 1+' 'tion has been read and that the contents thereof and all statements contained therein are GO!' 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 §53-13 1.01)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. gt% • Signature of Manager Applicant Signature of Spouse 4110. ACKNOWLEDGEMENT State of Nea County of 1Q k 145 The foregoing instrument was acknowledged before me this Ma.�+ IS, 0W/X by Rv4 T Siel4A. date name of person acknowledged Afro Seal t i "J No Pubs gnature 1 KIMBERLY A MILIER- J Genre ROM II l Stab of Motu . • 4 -- -- -4 4 . •lb- _ _ gh 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 ®Td}.,t��iq> 1Vt� . City ofOmafia, SAlebras � �� 1819 Farnam—Suite LC 1 �' 1 Omaha, Nebraska 681 83-01 1 2 ;:r ;; " ro Buster Brown (402) 444-5550 .o �� City Clerk FAX (402) 444-5263 �'�, ��4� EID April 17, 2012 RJN, Inc. Application to appoint Paul J. Slevin Dba"The Observatory Lounge" manager of your present Class "C" Liquor 2810 South 148th Avenue Circle License location Omaha,NE 68144 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 May 1, 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 fraudulent. gt% • Signature of Manager Applicant Signature of Spouse 4110. ACKNOWLEDGEMENT State of Nea County of 1Q k 145 The foregoing instrument was acknowledged before me this Ma.�+ IS, 0W/X by Rv4 T Siel4A. date name of person acknowledged Afro Seal t i "J No Pubs gnature 1 KIMBERLY A MILIER- J Genre ROM II l Stab of Motu . • 4 -- -- -4 4 . •lb- _ _ gh 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 City of Omaha, Webraskg f 1 1819 Farnam—Suite LC 1 2 � �, Omaha, Nebraska 68183-0112 0 r * " �` ' Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 Z 1 �9• FED April 17, 2012 Paul J. Slevin Application to be appoint manager of the Class 4109 Pierce Plaza., Apt #27 "C"Liquor License location for RJN, Inc., dba Omaha,NE 68144 "The Observatory Lounge", 2810 South 148`1' Avenue Circle Dear Liquor License Manager Applicant: This letter is ne•tification that a hearing before the Omaha City Council on your application to be appointed manager of the liquor license has been set for May 1, 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.:cl udulent. gt% • Signature of Manager Applicant Signature of Spouse 4110. ACKNOWLEDGEMENT State of Nea County of 1Q k 145 The foregoing instrument was acknowledged before me this Ma.�+ IS, 0W/X by Rv4 T Siel4A. date name of person acknowledged Afro Seal t i "J No Pubs gnature 1 KIMBERLY A MILIER- J Genre ROM II l Stab of Motu . • 4 -- -- -4 4 . •lb- _ _ gh 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 4 1 P'r y � cD 00 (Ob O D n .L. "� O N � O. C/� ��— O ,--, \ r .-3 hz, ›.-� 0 �, ih CTi (D CA 1 CD cn (D .fl 6.' CAD CCD riq cn CD N vl 1