RES 2012-0273 - Appoint Peter B Hagen manager of Spring Lake Golf Course , y '
yy,'' STATE OF NEBRASKA
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4 d -4941....ZZIA71 Dave HeinemanNEBRASKA LIQUOR CONTROL COMMISSION
�' _/ Governor j 2 FEB ,., , Hobert B. Rupe
B 6 P11 12 56 Executive Director
301 Centennial Mall South, 5th Floor
CITY '- "` P.O.Box 95046
i g '" "' Lincoln,Nebraska 68509-5046
OMAHA, 3t" Phone(402)471-2571
February3, 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: Spring Lake Golf Course
LICENSE #A-09634
Dear Clerk:
Enclosed is a copy of a manager application for Peter B. Hagen in connection'with the Spring Lake
Golf Course 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
ncil Meeting is grounds to recommend denial of your
application to the Nebraska Liquor Control Commission.
Sincerely yours,
„d0)41
Buster Brown
City Clerk
BJB:clj.
6 1i4:144.1*,:**.iiiiiot the above listed individual. Iüñderstand that my spouse and I are responsible for
0,0001W06.***1.00tiditiOn6':*-Otill** ;,0:iii,ts 40000nbaqiat!OeibOvg IndIvlduaI.has violated( 53-125(13))the
tbinnifitikin,M4iy.:CanC.et**voke-the:'114nor_itoenSe;
Ge---"J
Signature of individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of
County of The foregoing instrument was acknowledged before me this
7 / / a-- by
date name of person owledged
Affix
Seal GENERAL NOTARY.State el Nebraska
Notary Public signature CYNTHIA FORD THINNES
My Comm.Exp.August 16,2015
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 fixoist
FORM 35-4178
Revised 1/2008
1
orm 103
Rev 1/2011
Page 3 of 5
f .
MANAGER APPLICATION Dace Use RECEIVED
INSERT-FORM 3c
JAN 3 0 2012
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR
PO BOX 95046 CONTROL COMMISSION
LINCOLN,NE 68509-5046
PHONE: (402)471-2571
FAX: (402)471-2814
Website: www.lcc.ne.gov
Corporate manager,including their sponse,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
Name of Corporation/LLC: C 1"5( O f 0 hay 14I-41r P••' /itr
Premise License Number: A — 04 63
(if new application leave blank)
Premise Trade Name/DBA: Qr;KJ q LaY c. &v i c Low r Se..
Premise Street Address: LI v�.-O IAv c.4 o v- 1
City: 010.4 k' State: A)E Zip Code: to S 1 U-7
Premise Phone Number: Lit)Z — '-)zl`-1'— y L 30
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://www.lcc.ne.aov/license search/licsearch.cei
O PO OFFICER/MANAGMG MEMBER SIGNATURE
(Faxed signatures are acceptable)
Form 103
Rev 11/2012
Page 2 of 5
1200001937
-125(13))the
tbinnifitikin,M4iy.:CanC.et**voke-the:'114nor_itoenSe;
Ge---"J
Signature of individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of
County of The foregoing instrument was acknowledged before me this
7 / / a-- by
date name of person owledged
Affix
Seal GENERAL NOTARY.State el Nebraska
Notary Public signature CYNTHIA FORD THINNES
My Comm.Exp.August 16,2015
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 fixoist
FORM 35-4178
Revised 1/2008
1
orm 103
Rev 1/2011
Page 3 of 5
RECEIVED
Gender: 40 MALE °FEMALE NEBRASKA LIQUOR
CONTROL COM`MIS.SiON
I ast Name: First Name: +� MI:
Home Address(include PO Box if applicable): 10,3/6o i,). / -i'i 141 .5�"
City: WAAJACA County: DoVJle,S. Zip Code: ers ii lv
Home Phone Number: 4OZ- 6 S"f /Gd`I Business Phone Number 2- 1/4/4 tb 5-6
Social Security Number:_ Drivers License Number&State: . .�J6
•
Date Of Birth: Place Of Birth: ,51o1.1u R 1 f 5 5 D
• OYES ONo
Spouses Last Name: •s+y.,n First Name: u.eti MI: iA
Social Security Number: _ Drivers License Number&State: __ _
Date Of Birth: Place Of Birth: 011ikh6, ?E
CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
O yv a h' . A)6. 24) f teYx CAtAlui A1e ZOO' !?►'e sue-
( ,t eiwie41 e, PZ 2%04 Zeoy G 6 a)t, 42 zizq z ooL/
7.ov1 zoo _ .0a 1C1&Kc-1, iJE zdor 2..',3
Form 103
Rev 11/2012
Page 3of5
c.4 o v- 1
City: 010.4 k' State: A)E Zip Code: to S 1 U-7
Premise Phone Number: Lit)Z — '-)zl`-1'— y L 30
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://www.lcc.ne.aov/license search/licsearch.cei
O PO OFFICER/MANAGMG MEMBER SIGNATURE
(Faxed signatures are acceptable)
Form 103
Rev 11/2012
Page 2 of 5
1200001937
-125(13))the
tbinnifitikin,M4iy.:CanC.et**voke-the:'114nor_itoenSe;
Ge---"J
Signature of individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of
County of The foregoing instrument was acknowledged before me this
7 / / a-- by
date name of person owledged
Affix
Seal GENERAL NOTARY.State el Nebraska
Notary Public signature CYNTHIA FORD THINNES
My Comm.Exp.August 16,2015
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 fixoist
FORM 35-4178
Revised 1/2008
1
orm 103
Rev 1/2011
Page 3 of 5
i '
x
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
2e>=:6— Zees' -8,e1,50. Coo l f' Q,ui si -gob b t ooa_ — t 4 ti —5Qh'3
2c»S 2411" S Lt,t). .4 Vet_rI�r �G 1 e-rr �tuv�1 'ieL' 393- 1-11e3�
1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed
by both applicant and sponse,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
charges by each individ 's name.
• YES NO
Res,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)
7t. f ej 06/1193 L. 4.1 At( Sp.etol's Cut' I lc
l Con-F✓04,y trio �-kc D,.oApt� ..p.,... rcu,
le.- /4f i D8/ 1194 Deo,d«r000, s 0 qek70044 y ex a „tow-. ;.P "D 44.515 -P,- zt�
%).c - f.-� 07/1608 Autilif1 AlE W/litil {o e-ASI ?CudFi'ry 2. Have you or your spouse ever en approved r made application for a liquor license in Nebraska or
any other state? AYES 010
IF YES,list the name of the ptemise.
SviscJ et-thy &r 7 ei vb amp, )J
3. Do you,as a manager,qualify under Nebraska Liquor Contro Act(§53-13 1„Q1)and do you intend to
supervise,in person,the management of the business? 474 S UNTO
4. Have you enclosed the required fingerprint cards and PROPER FEES with this application?
(Check or mono order made payable to the Nebraska State Patrol for S38.00 per person)
'ES �TO
5. List any alcohol related training and/or.experience(when and where).
4),1i9
Form 103
Rev 11/2012
Page 4 of 5
A FORD THINNES
My Comm.Exp.August 16,2015
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 fixoist
FORM 35-4178
Revised 1/2008
1
orm 103
Rev 1/2011
Page 3 of 5
RECEIVED
n(���l AS ,A 1101,IIQR
The above individual(s), being first duly sworn upon oath, deposes and s�aa9nTlePtiee { L i®ae
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.
late,---7
6.. i„, -f---i-g ____,
Signature of Manager Applicant Signature of Spouse L/
ACKNOWLEDGEMENT
State of Nebraska ';'�-�
County ofa /4 S The foregoing instrument was acknowledged before e this
Ci
by P'*;1ei1 (�:r !,-�i�1 °eir)
date \-1(a_ric,,(1
name of person acknowledged
A
\ 1
Affix seat 1
No Public signature HEATHER STUEVE 1
1 General Notary 1.
1 State of Nebraska I
6 1
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
Page 4 of 5
A FORD THINNES
My Comm.Exp.August 16,2015
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 fixoist
FORM 35-4178
Revised 1/2008
1
orm 103
Rev 1/2011
Page 3 of 5
4
RECEII ,'r: * cti rUr :
vw
SPOUSAL,AFFIDAVIT OF office use
NON PARTICIPATION INSERT JAN 3 0 2012
NEBRASKA LIQUOR CONTROL COMMISSION �����SF` L �R
301 CENTENNIAL MALL SOUTH
PO I BOX COL95046,NE CONTROL COMJ 1ISSION
LINCOLN,NE 68509-5046 ...OM
MISSION
(402)471-2571
FAX:(402)471-2814
Website: www.lce.ne.gov
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t1/4_,_ A. •
• Signature of spouse asking f r waiver Printed name of spouse asking or waiver
(Spouse of individual listed below)
State of mt S ILa
County of 1)'oti514 S The foregoing instrument was acknowledged before me this
_AJ`�ua ,•:\ Q� y a 1\g. by ' �/�+ A...ka
1� acknowledged
I ��y D to of person
Affix Seal
Jlortilinidliodbmilswilbtairodbeialowilre
'Vaa ` ( HEATHER STUEVE 1
Notary Public signature General Notary 1
1 State of Nebraska I
. • •
� !'�t� a a cutgilc i NI r�lug` t dta n k t" ,kip is p Nam+ v + 'I
wse I A , W.7J yl':.. _ 4,4 31 C vio t(*53— '', 3) '.
;::y,�+ i 'fang' N ,y�, �,�y Icy �7j ' m, y� ' t {, g�i�e�.,, f4, t1 ,, +"eu� k Y@_t ..y ,
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YE-Cr,- 2-- 1C,- /7119g4 .-j'..
Signature of individual involved with application Printed name of applying individual '
(Spouse of individual listed above)
State of /Lt--1-/t-e-emu-'
County of The foregoing instrument was acknowledged before me this
// 7// a by P-t— 4_` -4-de_.
date name of person acknowled ed
_ I / Affix Seal RN.NOT to 01 tied.
- o� CYNTHIAFORDTHIN.Ii. ,
Notary Public signature • 1AfCaaas t]��9ust t'v.:'i>';-
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
Gity ofOmaha, J\lebras,Qa � kit
°Tt
• 1819 Farnam—Suite LC 1 e -�
Omaha, Nebraska 68183-0112 0� 4„ ' _;6, �'
Buster Brown (402) 444-5550 �t"
City Clerk FAX (402) 444-5263 0�'�ED FEBR��41-
February 14,.2012
City of Omaha, A Municipal Corporation Application to appoint Peter B. Hagen
Dba"Spring Lake Golf Course" manager of your present On Sale Beer
4020 Hoctor Blvd License location
Omaha,NE 68107
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 February 28, 20/.2 . 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
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k .m. . .. '''�`,,u.. : �'4 1c64!nac ....I k N yam' ., 4Y.,. 0.14.4 A.
iC — t.,.0"4 Mtlm.z`0101'— it41aFi
t1/4_,_ A. •
• Signature of spouse asking f r waiver Printed name of spouse asking or waiver
(Spouse of individual listed below)
State of mt S ILa
County of 1)'oti514 S The foregoing instrument was acknowledged before me this
_AJ`�ua ,•:\ Q� y a 1\g. by ' �/�+ A...ka
1� acknowledged
I ��y D to of person
Affix Seal
Jlortilinidliodbmilswilbtairodbeialowilre
'Vaa ` ( HEATHER STUEVE 1
Notary Public signature General Notary 1
1 State of Nebraska I
. • •
� !'�t� a a cutgilc i NI r�lug` t dta n k t" ,kip is p Nam+ v + 'I
wse I A , W.7J yl':.. _ 4,4 31 C vio t(*53— '', 3) '.
;::y,�+ i 'fang' N ,y�, �,�y Icy �7j ' m, y� ' t {, g�i�e�.,, f4, t1 ,, +"eu� k Y@_t ..y ,
1; mj '`7 11 .p..,.: ..jW �,._.„�..s.;„7„„ �ms.•,u Cwzi'.,,. .• !' D' _'' 5, 4V11.it d;.rw,: 1 '��:`�v3 �wrk`ftli'X. i J' ,' � a ,
YE-Cr,- 2-- 1C,- /7119g4 .-j'..
Signature of individual involved with application Printed name of applying individual '
(Spouse of individual listed above)
State of /Lt--1-/t-e-emu-'
County of The foregoing instrument was acknowledged before me this
// 7// a by P-t— 4_` -4-de_.
date name of person acknowled ed
_ I / Affix Seal RN.NOT to 01 tied.
- o� CYNTHIAFORDTHIN.Ii. ,
Notary Public signature • 1AfCaaas t]��9ust t'v.:'i>';-
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
Czty of Omoha "ebrieska
0„,Appi
1819 Farnam — Suite LC 1 rr :.'$v
Omaha, Nebraska 68183-0112 ®`� � �'�;1f^r
Buster Brown (402) 444-5550 __ "1""City Clerk FAX (402) 444-5263 ® �yP�
February 14, 2012
Peter Hagen Applications to be appoint manager of the Liquor
6316 North 1.49th Street License locations for The City of Omaha,
Omaha, NE 68116 at Johnny Goodman Golf Course, 6119 So 99th Str.
& Spring Lake Golf Course, 4020 Hector Blvd
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 February 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.
City Clerk
BJB:clj
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k .m. . .. '''�`,,u.. : �'4 1c64!nac ....I k N yam' ., 4Y.,. 0.14.4 A.
iC — t.,.0"4 Mtlm.z`0101'— it41aFi
t1/4_,_ A. •
• Signature of spouse asking f r waiver Printed name of spouse asking or waiver
(Spouse of individual listed below)
State of mt S ILa
County of 1)'oti514 S The foregoing instrument was acknowledged before me this
_AJ`�ua ,•:\ Q� y a 1\g. by ' �/�+ A...ka
1� acknowledged
I ��y D to of person
Affix Seal
Jlortilinidliodbmilswilbtairodbeialowilre
'Vaa ` ( HEATHER STUEVE 1
Notary Public signature General Notary 1
1 State of Nebraska I
. • •
� !'�t� a a cutgilc i NI r�lug` t dta n k t" ,kip is p Nam+ v + 'I
wse I A , W.7J yl':.. _ 4,4 31 C vio t(*53— '', 3) '.
;::y,�+ i 'fang' N ,y�, �,�y Icy �7j ' m, y� ' t {, g�i�e�.,, f4, t1 ,, +"eu� k Y@_t ..y ,
1; mj '`7 11 .p..,.: ..jW �,._.„�..s.;„7„„ �ms.•,u Cwzi'.,,. .• !' D' _'' 5, 4V11.it d;.rw,: 1 '��:`�v3 �wrk`ftli'X. i J' ,' � a ,
YE-Cr,- 2-- 1C,- /7119g4 .-j'..
Signature of individual involved with application Printed name of applying individual '
(Spouse of individual listed above)
State of /Lt--1-/t-e-emu-'
County of The foregoing instrument was acknowledged before me this
// 7// a by P-t— 4_` -4-de_.
date name of person acknowled ed
_ I / Affix Seal RN.NOT to 01 tied.
- o� CYNTHIAFORDTHIN.Ii. ,
Notary Public signature • 1AfCaaas t]��9ust t'v.:'i>';-
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
s
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Date Of Birth: Place Of Birth:
•
CITY &STATE YEAR YEAR CITY& STATE YEAR YEAR
FROM TO FROM TO
Form 103
Rev 11/2012
Page 3of5