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RES 2011-1282 - Appoint Louis M Valencia manager of American GI Forum Omaha Chapter ��NE srAr\ply 7' 2'' t [' �j I_, STATE OF NEBRASKA OIL 4 Y rn% r. NEBRASKA LIQUOR CONTROL COMMISSION ► ,a, Dave Heineman f O C T I I nil l 9. 11 ti i r...* - Governor Hobert B. Rupe Executive Director 301 Centennial Mall South, 5th Floor CITY LLLR!S P.O. Box95046 OMAHA, N,': .p A S i • Lincoln,Nebraska 68509-5046 Phone(402)471-2571 October 7, 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: AMERICAN GI FORUM OMAHA BRANCH LICENSE #CK-01251 • Dear Clerk: Enclosed is a copy of a manager application for Louis M. Valencia in connection with the American GI Forum 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, WO-d-Ai-r/J-1 G�L Jacqueline Rodriguez . Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION • 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 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOL,N,NE 68509-5046 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 CI 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 w ; :%?n ".a4kg I '.v� n. µ zs� r� r..::::,-... ....Ts-ac73; r, ' '� '' r y . :., s ems':.::. ti,{x ;s:.. ; n� E s, Name of Corporation/L,L,C: American GI Forum of the U.S. :GSM.. 1."."':t :iu'3l:.sv4 1': 2 . r� :�"./.r'.1��.. �t�i': . '�;'Ca P 1i...� , , t., .r �.._..Y. . APremise License Number:GK-01251 (if new application leave blank) Premise Trade Name/DBA:American GI Forum Omaha Chapter Premise Street Address:2002 'N'Street City:Omaha State:NE Zip Code:68107 Premise Phone Number:402-734-1147 The individual whose name is listed as a corporate officer or managing member as reported on insert fbrm 3a or 3b must sign their name below LIPiitte (14-: L „/, , , CORPORA E OFFICER/MANAGIN i MEMBER SIGNATURE (Faxed signatures are acceptable) m 103 11111111111011111 /2011 2of5 1100017638 ' ��ii !v3, •,w i fa, ,•••• .� ' `••"4, e� .L Zp �Y � w�`pL•he�� .. .�w1'.'••'•: :2. ,,..�.4: 'ri',"m,r . +� '!y��;.'rs,l1.k:;,,F'•,. ?rTiYanig�r?slrib 'Fa �, � „ ti a • ' a 1 y�Fx Y# nv> xi,'v . z ...... r, � % � L , a A cti4;:a � �,�� 7mi��' � dfln: i ,,,m.:ef• Ls..._. . r..'mc• :Z' ' : , k/�/b.e.4✓� v>,.x •� ._ :? . . . ": :,;•,. •tc: cc � ,. ,. :• •Gender: • MALE ❑ FEMALE ' Last Name:Valencia First Name: Louis • . MI: M Home Address(include PO Box if applicable):4210 So. 22nd Street City:Omaha County: Douglas Zip Code:68107 Home Phone Number:402-734-5961 Business Phone Number:402-734`1147 Social Security Number: - Drivers License Number& State: - ` -- - - • -— Date Of Birth: Place Of Birth: Omaha, NE Yw p,19 fwty y. , i• r; . .(�t . , q ^",A•°,y'�'FY x�„ :..w:... P. 'ttwR�r.. c'¢'.,, RtE9 f,t'�`a.F.e•. •"r' S wa �., 'r ',.,a' $rt&V.V'tt, .Sli1F o e. •'4...`41 ,,,,, ,l....,, !•a .,. CE!'.. .. 4: ;F' ..t 4..''f-}Li:S.. ❑■ YES ❑NO .t,, ',c t 1.43l K.FI:.$•is �: y�� 9 .s: L,S,.•(�v' )' .•�, ,� ia:;:.Y 142:.•.: , :. u/:^,'.i,. Zi•'=u• A 1..::�n.'n;z;i :rJb!'rY,+. .�tttr �.I'F i ,..++,,(([[��`' J �. 'i Y < ! >�� .' 'd''y�'-- •j�l� .k'il'x��!.1-V�V' Z�. -3'^ ., .•;.:;•. o .... •. ..-�:;sr.'y:4';L::,., ..�.i to :�, r,3r.�k ' a`jxE P' .to Spouses Last Name:Valencia First Name: Kathleen MI: R Social Security Number: - - - - — - Drivers License Number& State: - - - Date Of Birth: Place Of Birth: Omaha, NE "it :r.., .. ..ems t.::: . •.1-•,ro.. . 1,,z,..,..wx r ,..!,.. �f. `4% ,•4'.':a '` :'e Fk• .l 1:; lE`, ,�e ,i t.': i�,+ '' 4b� f l�t. ; .,r .l a i t. r: x:� :'_t - ..iC'i-f:a•�'`P!''�rtc:,:)-3 rr }:,'.. n.a:+' ,,=. A .x7C; •:; 'Ai,.i. ' ,',.,.-el,;.;„, t.. ,:}.•r, b�fp,�J`_. t a!•�+•r t SA 'E �. '4. .'4• • ;' a r,:3 w� !`:i.1..4.,-•:', .?..' , �+h i~::' ,S ,Fs:; 1;c.� ,•'4• .��` :' ��- ~,':_?`'r�3 2 `F,Cb �'•4 ..Y •.. ,.. CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1959 2011 Omaha, NE 1953 2011 Form 103 Rev 12011 Page 3 of 5 YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 1987 2009 City of Omaha Daryl! Giles 402-444-5700 1979 1987 Genuine Auto Mark Griffith y sf .fly l' h {� sp ►6 �'x t * A�I�P� Sl�:�l� 1 �; 1 WAND .i ,N• a i si:... .learly is1c .. .. ,:.. ?�. .,.<.,.z�.,8.^:��._, o, I.,, . 3.. .,... it ...,,. 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 ofeha ge ; ;L'A pposition 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? EYES ENO 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) DYES ONO Form 103 Rev 1/2011 Page 4 of 5 Place Of Birth: Omaha, NE "it :r.., .. ..ems t.::: . •.1-•,ro.. . 1,,z,..,..wx r ,..!,.. �f. `4% ,•4'.':a '` :'e Fk• .l 1:; lE`, ,�e ,i t.': i�,+ '' 4b� f l�t. ; .,r .l a i t. r: x:� :'_t - ..iC'i-f:a•�'`P!''�rtc:,:)-3 rr }:,'.. n.a:+' ,,=. A .x7C; •:; 'Ai,.i. ' ,',.,.-el,;.;„, t.. ,:}.•r, b�fp,�J`_. t a!•�+•r t SA 'E �. '4. .'4• • ;' a r,:3 w� !`:i.1..4.,-•:', .?..' , �+h i~::' ,S ,Fs:; 1;c.� ,•'4• .��` :' ��- ~,':_?`'r�3 2 `F,Cb �'•4 ..Y •.. ,.. CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1959 2011 Omaha, NE 1953 2011 Form 103 Rev 12011 Page 3 of 5 • • • AiS t '•G, M S y,}'g ( 5 ate, 111 �� ``' 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 fraudulent. !�?�.> Gi�:b-e _1 d am,'- i Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebras County of . Celt?"jam The foregoing instrument was ac owledged before me this g_ z, , 20// by 4 4., ticdi roc �_..., date name of person acknowle g )/174.e,e-i‘ �� Affix Seal t MIK pM,�111dNob111N& otary Public sight re YOLANDA D Dtb Comm.Egi. 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 :'_t - ..iC'i-f:a•�'`P!''�rtc:,:)-3 rr }:,'.. n.a:+' ,,=. A .x7C; •:; 'Ai,.i. ' ,',.,.-el,;.;„, t.. ,:}.•r, b�fp,�J`_. t a!•�+•r t SA 'E �. '4. .'4• • ;' a r,:3 w� !`:i.1..4.,-•:', .?..' , �+h i~::' ,S ,Fs:; 1;c.� ,•'4• .��` :' ��- ~,':_?`'r�3 2 `F,Cb �'•4 ..Y •.. ,.. CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1959 2011 Omaha, NE 1953 2011 Form 103 Rev 12011 Page 3 of 5 O � - 0 lity es? City of temafia, Nebraska A 41/4 ere- AtKIj+t 1819 Farnam—Suite LC 1 r , Omaha, Nebraska 68183-0112 Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 o44'4 FEBIL.°t.1- October 18, 2011 American G I Forum of the U S Application to appoint Louis M. Valencia Dba"American G I Forum Omaha Chapter" manager of your present Class "C" and 2002 "N" Street Catering Liquor 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 November 1, 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. Sincere, yours, Buster Brown City Clerk BJB:clj Gi�:b-e _1 d am,'- i Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebras County of . Celt?"jam The foregoing instrument was ac owledged before me this g_ z, , 20// by 4 4., ticdi roc �_..., date name of person acknowle g )/174.e,e-i‘ �� Affix Seal t MIK pM,�111dNob111N& otary Public sight re YOLANDA D Dtb Comm.Egi. 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 :'_t - ..iC'i-f:a•�'`P!''�rtc:,:)-3 rr }:,'.. n.a:+' ,,=. A .x7C; •:; 'Ai,.i. ' ,',.,.-el,;.;„, t.. ,:}.•r, b�fp,�J`_. t a!•�+•r t SA 'E �. '4. .'4• • ;' a r,:3 w� !`:i.1..4.,-•:', .?..' , �+h i~::' ,S ,Fs:; 1;c.� ,•'4• .��` :' ��- ~,':_?`'r�3 2 `F,Cb �'•4 ..Y •.. ,.. CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1959 2011 Omaha, NE 1953 2011 Form 103 Rev 12011 Page 3 of 5 otodi A,, NF — - oiir City of emafia Nebraska 411101/4 Ore)-4\tirili 1819 Farnam—Suite LC 1 i t1 d Omaha, Nebraska 68183-0112 os `� Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 O�`�1Fp FEBR�1,..4i• October 18, 2011 Louis Valencia Application to be appointed manager of the present 4210 South 22nd Street Class "C" and Catering Liquor License for American Omaha,NE 68107 G I Forum of U S, dba"American G I Forum Omaha Chapter", 2002 "N" 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 November 1, 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 Signature of Spouse ACKNOWLEDGEMENT State of Nebras County of . Celt?"jam The foregoing instrument was ac owledged before me this g_ z, , 20// by 4 4., ticdi roc �_..., date name of person acknowle g )/174.e,e-i‘ �� Affix Seal t MIK pM,�111dNob111N& otary Public sight re YOLANDA D Dtb Comm.Egi. 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 :'_t - ..iC'i-f:a•�'`P!''�rtc:,:)-3 rr }:,'.. n.a:+' ,,=. A .x7C; •:; 'Ai,.i. ' ,',.,.-el,;.;„, t.. ,:}.•r, b�fp,�J`_. t a!•�+•r t SA 'E �. '4. .'4• • ;' a r,:3 w� !`:i.1..4.,-•:', .?..' , �+h i~::' ,S ,Fs:; 1;c.� ,•'4• .��` :' ��- ~,':_?`'r�3 2 `F,Cb �'•4 ..Y •.. ,.. CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO Omaha, NE 1959 2011 Omaha, NE 1953 2011 Form 103 Rev 12011 Page 3 of 5 0 n - (7 N h7 j C.). ,t 5' fro N O IQ • iIr � O N � ,ram a p O `� A) ti O• O c0 • �. cu 0 o CI- n Na P)