Loading...
RES 2011-0787 - Appoint Joyce Warren manager of Big Jim's Plus nks r�PZ.;;N V '•} ,y=..._...,5n /1%y = V '�', R FT C E i V _, D STATE OF NEBRASKA ;a; y,W`��'-,-/�i�>, ,,.�; ".s' Dave Heineman NEBRASKA LIQUOR CONTROL COMMISSION i,1yjlAi^% a1' Governor ( l � � �s dr Hobert B. Rupe 49R .�86�_ r 9 Executive Director 301 Centennial Mall South, 5th Floor P.O.Box 95046 CITY CI r R , Lincoln,Nebraska 68509-5046 0MriNQ iIE=i''j C Phone Fax(402)4712814 June ;'2•011 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ City Clerk of Omaha 1819 Farnam LC1 Omaha, NE 68183 RE: Manager Application Submittal Dear Sir/Madam: The corporation Big Jim's Plus LLC DBA Big Jim's Plus submitted the enclosed Application for Corporate Manager and has liquor license(s) Class D 52286. The applicant's name is Joyce Warren. Please present this application to your City/County Council and return the results of the action taken to our office. If you have any questions or comments, please give me a call at (402) 471-4881 . Sincerely, Jackie B. Matulka Licensing Division Enclosure Janice M.Wiebusch Bob Logsdon Robert Batt Commissioner Chairman Commissoner An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper ss./Superv) Metropolitan Utilities Dist Utilities District Omaha Public School Subdist 7 School Board Ward' Mayor of Omaha Mayot State Board of Education Dist8 StatelBoard of Education Learning Community 1 -Dist 5 Le*:r ng Community Coordinating Council tormaci qr esRaAgt Copyright 2008'EIec IlS ste s Ind Software.All rights reserved. Vot 1.11.888.0 • I II httnc•//wun:v vnternhenle nPrvr nP anv/VntPrVimw/RPaictrant4Parnla Nn•icacainnirl=1176Ah5 Ail/W11 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 ' T . MANAGER APPLICATION Office Use mECEIVED n , INSERT-FORM 3c j rn NEBRASKA LIQUOR CONTROL COMMISSION JUN 2 NU 301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR •PO BOX 95046 CONIRQl.COMM11SS10N LINCOLN,NE 68509-5046 CY4111 PHONE: (402)471-2571 FAX: (402)471-2814 Website:www.lcc.ne.gov 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 their fingerprints(2 cards per person)and fees of$38 per person, made payable to the Nebraska State Patrol 5) Must be 21 years of age or older 0 6) Applicant may be required to take a training course ctiA).} Qorporation/LLC infbrination • Name of Corporation/LLC: /31(" Tim '5 1'LoS L. L C A- /1Jeb/1- s-gd), 4„ii;la C4a44, l'Y Comboi(.`1 Premise information . ` ' . ' ' ,, , , ' `�--,- Premise License Number:_ 5-2 Z 8 C. (if new application leave blank) Premise Trade Name/DBA: 6 i Cr t 's PLu$ Premise Street Address: 302.yf .4mc5 A ii I- City: ©r►a A CI State: N E- Zip Code: ( am /// Premise Phone Number: V4 Z -'I C3- Zol 3 The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b must sign their name below N .4e,e- Q ,e, CORPO TE OF ICER(JIANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) 1100009924 Copyright 2008'EIec IlS ste s Ind Software.All rights reserved. Vot 1.11.888.0 • I II httnc•//wun:v vnternhenle nPrvr nP anv/VntPrVimw/RPaictrant4Parnla Nn•icacainnirl=1176Ah5 Ail/W11 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 FREE,. 05-31-2011 00:05 WAR Tr • - •- • . . . , . t.Orporove manager*incensuaz weir sminse:..are reurnren TO,roxine.; Tr: ,1* • j ros u oozes or Ike Mute°3tates • Muni uu kiioilfailiai.rf.eadfai•iLiiitiner 4- and IlInvf Orntrief Dr4.1.11 " yter - *TRW Otrieprasha -3) Must provide a COPY nt one ot the tollownin:state issued US birth certificate,.naturalization [raper.Or 143 pininpOrr • Mu ict=PIM:Melt lingerPrials -cards Otr PerSeti)anti fees ors.3it Per person.wade amble to thelYobrasita Mare Yatrat Must be 21 c.rs ore or older 6) Applicant May be:required to take a training'eourse • • • ir •i.".t,gfz. , , , . , . • • . • • Nanle.ette0Torkitjon/LEZ: ,t3t fr. 1;24 /2kii.S,.• • ah, " • " - • :ff!•••,-, T"V - ft!: sc:t4c; c Number ; (irrie.w appiEettion•leave blank) Frouir,e Trade NeriteibnA: &Br4MPti) .• Premise gtivetAddretg: ....30 .41 4.1/65. AL'L.-. City: Ort/olo &ate: /11- Zip.Codo; Premise Mee Number: 4140 - S- . . . - • • • • be-IthYMUai whe. is#istØ aszpoue oMcr ormanangmmboAs irdadgmiusgh. Rrjb invst Ortfieir nam belulk ItAi 'OFF . lviANACING MEMBER SIONATUkE (Faxed signatures are acceptable) Fortii.10.3 110 140i1 r*Lif5 • . . • • '," • .:.: * ** . . • • . • • ' '• . . • . • . 05-30-2011 23:36 ... .. 1100009924 Copyright 2008'EIec IlS ste s Ind Software.All rights reserved. Vot 1.11.888.0 • I II httnc•//wun:v vnternhenle nPrvr nP anv/VntPrVimw/RPaictrant4Parnla Nn•icacainnirl=1176Ah5 Ail/W11 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 Manager's information must be completed below PLEASE PRINT CLEARLY Gender: ❑MALE 1 FEMALE Last Name: AMP-t M First Name: to-iCe. MI: p Home Address(include PO Box if applicable): (20.50 60 viJ1/LY et io o,Y..s QLAGe City: arl A-git County: 7)01.(- .41, Zip Code: <o 8 l 5 Home Phone Number: r,L - 511. 99 . 'tD Business Phone Number: (to 2, I$3- 20/3 Social Security Number:_ _ - , . - Drivers License Number&State. Date Of Birth: Place Of Birth: A LT f k,,t4 r, A 42K4NS A-5 Are you married?If yes,complete spouse's information(Even if a spousal affidavit has been submitted)`" \/. ❑ YES 2 NO R-ec2ext-Hx4 Al n� /11/1/tris�O IAA:0101A-td Spouse's information - • '-, Spouses Last Name: First Name: MI: Social Security Number: Dri -rs License Number& State: Date Of Birth: Pla e Of Birth: APPLICANT & SPOUSE MUST LIST RESIDENCES)FOR THE PAST TEN(10)YEARS APPLICANT SPOUSE - ' CITY & STATE YEAR YEAR CI Y & STATE YEAR YEAR �� Jb����FROM TO FROM TO ttD.-c D Cs 11 WE .m, ht4 /frE ( SIC 2 Aoo,' ,io// 156 3 ,,Ivtr leal(eY Al 0n.,4-/M Ni. 6 S( 9 11?‘ ?OD/ Form 103 Rev 1/2011 Page 3 of 5 . lviANACING MEMBER SIONATUkE (Faxed signatures are acceptable) Fortii.10.3 110 140i1 r*Lif5 • . . • • '," • .:.: * ** . . • • . • • ' '• . . • . • . 05-30-2011 23:36 ... .. 1100009924 Copyright 2008'EIec IlS ste s Ind Software.All rights reserved. Vot 1.11.888.0 • I II httnc•//wun:v vnternhenle nPrvr nP anv/VntPrVimw/RPaictrant4Parnla Nn•icacainnirl=1176Ah5 Ail/W11 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 • .. b. .� ,q 4.-.4r* sf E_, S i •' T TW(} ki 4)'' RS _ _ .:�t • YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO /� NUMBER :>02. *ii.,- ///v VA, 9�d, L1.0 , &-2.F 4 v2- #.c3-20/3 /4/7K OD;- vibies Amoco Sc- 4/02.-q53 -20/3 MANAGER`AND SPOUSE MUST REVIEW AND ANSWER THE QUESTIONS BELOW Please prhit dearly. 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 ICI NO If yes,please explain •elo or attach a separate page. Name of Applicant Date of Where Description of Charge Disposition Conviction Convicted (mm/yyyy) (city&state) 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? MYES ONO \1. IF YES, list the name ofth'e premise. �I& 37A4 22"-'s l - 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? Z.YES 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 Patr I for$38.00 per person) YES ONO e 0 1� ) ( .\ (-2 Form]03 /?p./ Rev 1/2011 Page 4 of 5 1.11.888.0 • I II httnc•//wun:v vnternhenle nPrvr nP anv/VntPrVimw/RPaictrant4Parnla Nn•icacainnirl=1176Ah5 Ail/W11 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 • ks PERSONAL OATH AND,CONSENT OF INVESTIGATION • 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 fraud il ; (.)44"1"(- Si, .tur: of Manager Applicant Signatur: of Spouse ACKNOWLEDGEMENT State of Nebraska County of O(,( �',(� The foregoing instrument was acknowledged before me this Yf 2 .3l 00 ao-rl date byc46-/Cfi name�f person acknowledged Affix Seal OWL NOTARY.Ste of Womb Notary Public signature MARYA.MASON — Comm.. .. 25,2814 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 1 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 01,ANHA, City of Omaha, fI'Tebras&a � ,.., 1NI i 84/ .adi0 mow. 0"%rolk,Vi 1819 Farnam— Suite LC 1 ® it d r Omaha, Nebraska 68183-0112 o .:, Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 o�'� F BR\ t.41. June 14, 2011 Big Jim's Plus, LLC Application to appoint Joyce P. Warren Dba"Big Jim's Plus" manager of your present Package 3024 Ames Avenue 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 June 28, 2011 . 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 ACKNOWLEDGEMENT State of Nebraska County of O(,( �',(� The foregoing instrument was acknowledged before me this Yf 2 .3l 00 ao-rl date byc46-/Cfi name�f person acknowledged Affix Seal OWL NOTARY.Ste of Womb Notary Public signature MARYA.MASON — Comm.. .. 25,2814 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 1 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 • City of Omaha, fAre bras a ""7 VGlt 4% 1819 Farnam—Suite LC 1 z Omaha, Nebraska 68183-0112 ®"• ,�.- ' .' Buster Brown (402) 444-5550 oto City Clerk FAX (402) 444-5263 0'Q9TtD FBR°44� June 14, 2011 Joyce P. Warren Application to be appointed manager of the present 6050 Country Club Oaks Place Package Liquor License location for Big Jim's Omaha, NE 68152 Plus, LLC, dba"Big Jim's Plus", 3024 Ames Avenue 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 June 28, 2011 . 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 ACKNOWLEDGEMENT State of Nebraska County of O(,( �',(� The foregoing instrument was acknowledged before me this Yf 2 .3l 00 ao-rl date byc46-/Cfi name�f person acknowledged Affix Seal OWL NOTARY.Ste of Womb Notary Public signature MARYA.MASON — Comm.. .. 25,2814 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 1 1 � & 'f�hAp ...? .,. .{p� .: .avr r f -•1!:-.3 4< e 3: s -^�' 8�ro- d. k:.r' ' .�U ,.r 1 e c,t x Po v,sr,. y1 ,h?j. • 3q"^"`y: ; y� r q jryi k t4-J I,F4 .nt -4 k a.r a .yrt rztt :...{`'r cL •tY ,• ., .N 'iw..y' Pbr,�.. : tt•I P1'"tR - li ✓ T%S',' -a -' A + n• 1 'S .:,� yZ'i,��. <! n ".... �L... .:Tc._ , ... ... ... _1 c"^` l.at." ,e,t,o_.. 1 ►Si ,x,..1,4ii:l..... i 'k0S( tci ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) 1.State of /V e- sj( County of qS The foregoing ins iU� ltrument was acknowledged before me this c i q/i/ by !� a� UJ4�C A' kies d ate name of person acknoedged Affix Seal .r CI:N-:RAL NOTARY-State of Nebraska Notary Public signature MICHELLE A LAWLESS r • - my Comm.Exp.Sept.15,20l 1 1 �>�q :� a,:,.5rr. -s T•i "-' u :..',��.�:„,iw>J ",.4;.,..,.:.,. ti q >''- �':.,.--;'r'x«`,. ' a ",rs'c-+<'F i'''{*.":�'3.. Id. a :!yn.' a .:•i l"� t�e,eote�, ac 1, do.4 ��sri3"'r °� pl��r Z��g"n% i; ,,rg e � ek I4� ky.0L-1 �yry:ir. .",3'I�tior�r:e o¢ x«(ate t: Y e a1 a I ' -.a ¢ .s W.. '' Ar T-,t �: .1,i, sr A.t.e,'*-x ,•-. i,'2 5�..,.�. • - ,r;r��f .,'r,S, ,i-t ,b `o' d�'i - e"x.�t-E"1;. i Y F 1,,!,,,� t,,e t ZED k)rp�1 da '� cr a,7 ., s „ rj 1 r ;y 1(r'4' nr arl, 4,vAod t r1 a3(t '',,',,,If-c �t b Jq ,' p,,,. °��" ,e 1 nL} 9..PRc a '4'"." e.4,Xtrir A +:.'i,2 -,fin..,. r. .+ _¢.f.� i,, s. t' : �^' ---- k ry 44}. s J u ?- ftc ., `'v.t_ i,..:. ',� ��d, a :'© o b' ..'p:,;..,.`2-a1`I T"?'1F� eT� e.r $ t..... t r. '' :v ,s'��.1 .7 J'j.rr -'i. - Signatur o ividual involved with application Printed nalpof applying individual (Spouse of individual listed above) State of �e,bvzt S�t County of 1Q_S The foregoing instrument was acknowledged before me this fitit07,c5��3�/� • layf/t //ems date name cif person acknowledged k. '// r]� , „ J jij I Affix Seal NERAL NOTARY-State of Nebraska Notary Public signature { MICHELLE A.LAWLESS My Comm.Exp.Seet.15.2011 -- 1 I In compliance with the ADA,this spousal affidavit of non participation is available in other form for persbn�with disabilities. A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1l2008 N • b a1 . n N UQ O N a Cr1 '— UG ..• -21 .................„.....„ . 0 , -......\ \ Dli o co • a °