RES 2012-0101 - Appoint Louis A Wright manager of Native Omaha Club 4,(ylE
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STATE OF NEBRASKA
".-_i�/�� ,mow It Dave Heineman � � �,w�, O ?,, , � ; ,� NEBRASKA LIQUOR CONTROL COMMISSION
'�i t'\t:rt 'a' Governor Hobert B. Rupe
Executive Director
301 Centennial Mall South,5th Floor
�`•',' �=, , , ' r'1 P.O.Box 95046
Lincoln,Nebraska 68509-5046
Phone(402)471-2571
December 27, 2011 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: Native Omahans' Club
LICENSE #C-47814
Dear Clerk: •
Enclosed is a copy of a manager application for Louis A. Wright in connection with the Native
Omahans' Club 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
BJB:clj
own
City Clerk
BJB:clj
WILLIAM F.WADE
otary Public signature
My Comm.Eio.Joie 4,2013
IONic-v-ledge that I atthe spouse oftheitbovelisied indiVicTual. UrKleistand that tny spouse and I are risiOnsible-for
1compliance with the conditions set out above. If it is determined that the above individual has violated(§53-125(13))the
C;iilininission may cancel or revoke the liquor license.
c;le 2,464 jzS5i ca- C-.
Si ature of individual i vo ed with application Printed name of applying individual
ouse of individual li above)
State of
County of 9 _ The foregoing instrument was acknowledged before me this
/ //0/1/ I by - .-eSfcdt). gel,( 778
/ date name of person acknowledged
0--LePidetb,l'a6e6- Affix
GENERAL NOTARY Stale of Nebraska'
Notary Public signature MINA F.WADE
My Went Exp.June 4,2013
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 35-4178
Revised 1/2008
FROM TO
D1ilcS a oa5:20!1 Dva a.r+d PccxtcI Ks aoo5 cR of f
VV12. 2s j C pegFi_. a 003 aobS atYCJ FL 1003 ai Form 103
Rev 1/2011
' Page3of5
MANAGER APPLICATION office use
INSERT-FORM 3c
NEBRASKA LIQUOR CONTROL COMMISSION
301 PO BOX 95L MALL SOUTH 046 RECEIVED
LINCOLN,NE 68509-5046
PHONE: (402)471-2571 DEC 2 7 2011
FAX: (402):471-2814
Website:www.lcc.ne.gov NEBRASKA LIQUOR
Corporate manager,including their spouse,are required to CONTROL,to t6e'3o�owingg requiION rements
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 their fingerprints(2 cards per person)and fees of$38 per person,made payable to
the Nebraska State Patrol
5) Must be 21 years of age or older
6) Applicant may be required to take a training course
yt, S V f pp ,+.3a( i '' /' trv0a4-4761;.,( '`u .+ii .m '�'r-fi`:. "r ;ik'fS;.r.+re'b L„2: ,,?
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Name of Corporation/LLC: /( ✓E OrHAMS (l.u8, ,. ,C.
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Demise License Number:
(if new application leave blank)
Premise Trade Name/DBA: WATvE 0 74/.(A (.u$
Premise Street Address: 361 et 1J ANT* S'7;e E ET—
City: h ,4 NI State: AlE Zip Code: 68//i
Ptenise_P hone Number "I O P.- y57 —5 97q
The individual whose name is listed ar a corporate officer or managing member as reported on insert form 3a
or 3b i their name below
471
` CO ICER/MANAGING MEMBER SIGNATURE
(Faxed signatures are acceptable)
___ ill - --- illForm 103
Rev 1/2011
Page 2of5
1100 20970
with disabilities.
A ten day advance period is requested in writing to produce the alternate format
FORM 35-4178
Revised 1/2008
FROM TO
D1ilcS a oa5:20!1 Dva a.r+d PccxtcI Ks aoo5 cR of f
VV12. 2s j C pegFi_. a 003 aobS atYCJ FL 1003 ai Form 103
Rev 1/2011
' Page3of5
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Last Name: tolk/GHT— First Name: kotits MI: A
Home Address(include PO Box if applicable): 75151 Alf. 8671( /I'VE
City: 074/14 County: botilikAs. Zip Code: AIF
Home Phone Number: (ifesz.)5781567 Business Phone Number: C4/02-) 32.6—C/6
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Spouses Last Name: Afte/elf r-- First Name: .n.sysivA/k- MI: ...6
Social Security Number: ____ Drivers License Number&State: ? A/P
Date Of Birth: ' Place Of Birth: AfEkVolfeK, A/.7-- 1
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FROM TO FROM TO
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Form 103
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FROM TO NUMBER
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1 READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY.
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
charges by each individual's name.
YES ❑ NO
If 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)
/4 #L A- Wrier— `(//9960 0704 N� Leala C'aa)Amc,8" ic;*E pc
�rss�iS �• £c)4 NTT $/ oy G(ra4,Ali' 4uS fiAJE/iC:sees Fiavo)
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�G s�/S' A . �i� iv 616 be.SITE f &Piit 77E0-" FrNE PALo
skoi
2.. .r Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other-state? OYES [NO
IF YES,list the name of the premise.
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? ,rYES ONO
.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)
1:1 YES ONO
Form 103
Rev 1/2011
Page 4 of 5
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Spouses Last Name: Afte/elf r-- First Name: .n.sysivA/k- MI: ...6
Social Security Number: ____ Drivers License Number&State: ? A/P
Date Of Birth: ' Place Of Birth: AfEkVolfeK, A/.7-- 1
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FROM TO FROM TO
7S/ty A i. B6YR 4gir 5/11x41,9 rtmosi-
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lyriliffi,411/0#°-3
6/i? ew Ave
07ANA, Ai e 68/e>41
. _
Form 103
Rev 1/2011
Page 3 of 5
RECEIVED
yre" {S` 13'''f: '9"�� eref A 52 kul §
,``41` aa' xi .N_. -"�( ,i3 �.
�.�, :��;r�aYxk'- ... ���1 B
ASKA LIQUOR
CONTROL COMM QN
The above individual(s), being first duly sworn upon oath, deposes and states that the undersign is
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 applicants) 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 t• cancellation if the information contained herein is incomplete, inaccurate, or
fraudulent.
%nature er • pplicant Signa - _.-..-_.- —! _—_--
"�N •A M WILSON
MY COMMISSION EXPIRES
�_ Ortobsr 11,2015
ACKNOWLEDGEMENT "� 10 lz.I VIA I%
State of Nebraska E
County of toteaLAS The foregoing instrument was acknowledged before me this
;p e/3A • .7.0, .240if by ""�^-,� �/�
date �7 n�efe of person acknowledged
Affix Seal ► `1.. I ' ♦..
No •STEVE num=
Ostend aotr.
I Sias of Nebraska
- - - — = - - :Tim._
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 1/2011
Page 5 of 5
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Spouses Last Name: Afte/elf r-- First Name: .n.sysivA/k- MI: ...6
Social Security Number: ____ Drivers License Number&State: ? A/P
Date Of Birth: ' Place Of Birth: AfEkVolfeK, A/.7-- 1
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FROM TO FROM TO
7S/ty A i. B6YR 4gir 5/11x41,9 rtmosi-
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lyriliffi,411/0#°-3
6/i? ew Ave
07ANA, Ai e 68/e>41
. _
Form 103
Rev 1/2011
Page 3 of 5
Print Form
SPOUSAL-APFIDAVIT Off' Office Use
NON PARTICIPATION INSERT
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 -
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814
Website: www.lcc.ne.aov
, - 3,. ' -, 'rF r- s l ..�^t i .fit F-^ .:a„ itnr r' P
61. o a fia:it or; se hoide . sx e below co tms ghat I will haver,,,,. , e any:
y e radon t oft e business t53- 25(13)of the Liquor Control Act. I twill not
! t1; its ek she { c e° 1 of or re `res t.m self as the own'eraor n
Y
t1' p� e i t e da', o"r1 ape t o o s b e .in y capaacity I utt eist d my fingerprint w111 not be
r }t ok- Zi 1 y 1 .i I ., r applications needed�tti process�ls
f sr} ^ f +.ski"bx � � � � �„� `�1^�1 ...� 7�et � yy,,,) .: r
i i dr
`''�Il�1C�..-` �,���,.. .�..�:i ������`. ...Sni�4°° 1,h„�.i?ti.�u,.».w;���. _.s, •d:.i �._ra x..,,.fi"nC`.*, J,ilk:. ,r r.
) i /
//L U ; .l..Y�Mile 4./- Mity7A
igna use asking for waxer Printed name of spouse itskmg for waiver
(Spouse of individual listed below)
State of AtF,&c4-3-Kdi
County of 1301 Ld S The foregoingl instrument`warms acknowledged" before me this
410,de yeetz 2 2 )// by 11Y1Q� V`-� '� V L'�
(l date natrn of�nn ec owlnjine
J l I l Affix Sc,1:>'' AI A M WIL90N
Notary Public signature k .►N.
October
COMMISSION1, SPIRES
2015
f �o`. l't it nn+ o¢ e,llstee dtiidual 'x IIu1 er d�m iodise and I are%"responsible for
-W Athe m ,3 ,t ko.i e;.�� ter` ied that theeabove ind1vt "hasfvio ated( 3 � 5(13))thy.
!Commisstoni celor re oke the liquor'l nse� . .;... ', .: .� ? ;.
Lows it. / ��_
of ' t u • v ed with application Printed name of applying individual
(Spouse of individua listed above)
State of detreAsitit
County of: . 7/r4S The foregoing instrument was acknowledged before me this
bEC re e 1 20 a,D// by 1,,,k,,A(J '
date name of person acknowledged
Affix Seal
. r. --r-
Notary Public signature
In e with tliii 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
•STEVE[MINNOW FO 3S-4178
r! Nebtik.
8 R 1/2008
.ity.Coml ulon Expires Nov 16,2014
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-.`.-Ci'fY&STATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
7S/ty A i. B6YR 4gir 5/11x41,9 rtmosi-
07A114 NE 615/xx.
lyriliffi,411/0#°-3
6/i? ew Ave
07ANA, Ai e 68/e>41
. _
Form 103
Rev 1/2011
Page 3 of 5
•
HA, 1N
Cityo Omaha Nebras
ti)r c
hlt
1819 Farnam—Suite LC 1 Z rt �'? d
r.
Omaha, Nebraska 68183-0112 0 ve r-- k. ' _
Buster Brown (402) 444-5550 A ti'
City Clerk FAX (402) 444-5263 °'P 4:6
-gTtD FEBRUt►
January 10, 2012
Native Omahans Club, Inc. Application to appoint Louis A. Wright
Dba"Native Omaha Club" manager of your present Class "C"
3819 North 24th Street Liquor License location
Omaha,NE 68111
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 January 24, 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,
.1159
Buster Brown
City Clerk
BJB:clj
V`-� '� V L'�
(l date natrn of�nn ec owlnjine
J l I l Affix Sc,1:>'' AI A M WIL90N
Notary Public signature k .►N.
October
COMMISSION1, SPIRES
2015
f �o`. l't it nn+ o¢ e,llstee dtiidual 'x IIu1 er d�m iodise and I are%"responsible for
-W Athe m ,3 ,t ko.i e;.�� ter` ied that theeabove ind1vt "hasfvio ated( 3 � 5(13))thy.
!Commisstoni celor re oke the liquor'l nse� . .;... ', .: .� ? ;.
Lows it. / ��_
of ' t u • v ed with application Printed name of applying individual
(Spouse of individua listed above)
State of detreAsitit
County of: . 7/r4S The foregoing instrument was acknowledged before me this
bEC re e 1 20 a,D// by 1,,,k,,A(J '
date name of person acknowledged
Affix Seal
. r. --r-
Notary Public signature
In e with tliii 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
•STEVE[MINNOW FO 3S-4178
r! Nebtik.
8 R 1/2008
.ity.Coml ulon Expires Nov 16,2014
.a— - -i .--.,•-• .-latiftistotoi ' --itiatiwvx. '.- ii- -- - 1:•-•.t.%..t,-14.40Nt*eit'i
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",,,, ;le "., •,,,,' v rr, %.-,, :P...., ,-„f,-, ..,...:-.3,44;--0:-''-'„4.,,,.... .1-$40,,,,,'. - i,-', '-'":..-gt.gi .,=,' ^;'`...t'c ,-, • . ,.17,.0.7ierikteq51,p''..eif-"--''
1,J
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-.`.-Ci'fY&STATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
7S/ty A i. B6YR 4gir 5/11x41,9 rtmosi-
07A114 NE 615/xx.
lyriliffi,411/0#°-3
6/i? ew Ave
07ANA, Ai e 68/e>41
. _
Form 103
Rev 1/2011
Page 3 of 5
CityofOma/ia, Webras&a � A
1819 Farnam—Suite LC 1 rzetrliti,
Omaha, Nebraska 68183-0112 o "T .
Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263 o4, �E�Rv�I-
January 10, 2012 •
Louis A. Wright Application to be appoint manager of the Class "C"
7514 North 86th Avenue Liquor License location for Native Omahans Club,
Omaha,NE 68122 Inc., dba "Native Omaha Club", 3819 North 24th Str
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 January 24, 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
ka Liquor Control Commission.
Sincerely yours,
.1159
Buster Brown
City Clerk
BJB:clj
V`-� '� V L'�
(l date natrn of�nn ec owlnjine
J l I l Affix Sc,1:>'' AI A M WIL90N
Notary Public signature k .►N.
October
COMMISSION1, SPIRES
2015
f �o`. l't it nn+ o¢ e,llstee dtiidual 'x IIu1 er d�m iodise and I are%"responsible for
-W Athe m ,3 ,t ko.i e;.�� ter` ied that theeabove ind1vt "hasfvio ated( 3 � 5(13))thy.
!Commisstoni celor re oke the liquor'l nse� . .;... ', .: .� ? ;.
Lows it. / ��_
of ' t u • v ed with application Printed name of applying individual
(Spouse of individua listed above)
State of detreAsitit
County of: . 7/r4S The foregoing instrument was acknowledged before me this
bEC re e 1 20 a,D// by 1,,,k,,A(J '
date name of person acknowledged
Affix Seal
. r. --r-
Notary Public signature
In e with tliii 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
•STEVE[MINNOW FO 3S-4178
r! Nebtik.
8 R 1/2008
.ity.Coml ulon Expires Nov 16,2014
.a— - -i .--.,•-• .-latiftistotoi ' --itiatiwvx. '.- ii- -- - 1:•-•.t.%..t,-14.40Nt*eit'i
54':'4!t t9.41.1W' ..AN,.,' 4
it't,i'' i:Xyk, ,,..2.„,„Ez, Ii'L ....-; ,.'n,•..t:',, ; ..Y.,„!,,,''.1k,l'.4 gh,y.„,,,':f 4 'IX',..,eck eit Si.',-...1174;1'11,--."4 .1%, 'i "2 yS- -'a ' 'I''' ,r). 4s` gi'it:t/,`C`''''',,a1
",,,, ;le "., •,,,,' v rr, %.-,, :P...., ,-„f,-, ..,...:-.3,44;--0:-''-'„4.,,,.... .1-$40,,,,,'. - i,-', '-'":..-gt.gi .,=,' ^;'`...t'c ,-, • . ,.17,.0.7ierikteq51,p''..eif-"--''
1,J
,-.4...
-.`.-Ci'fY&STATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
7S/ty A i. B6YR 4gir 5/11x41,9 rtmosi-
07A114 NE 615/xx.
lyriliffi,411/0#°-3
6/i? ew Ave
07ANA, Ai e 68/e>41
. _
Form 103
Rev 1/2011
Page 3 of 5
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