RES 2011-1363 - Appoint Jeffrey S Buntgen manager of Granite City Food & Brewery •
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? `t STATE OF NEBRASKA
r �, a£ Dave Heineman 9 � � I µ NEBRASKA LIQUOR CONTROL COMMISSION
,
Governor I fi Hobert B.Rupe
.1, sae! Executive Director
�"w t• 30] Centennial Mall South,5th Floor
• .' , .q ? �' ." +.. ' P.O.Box 95046
` Lincoln,Nebraska 68509-5046
Phone(402)471-2571
November 9, 2011 Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(T1Y)
web address:http://www.lcc.ne.gov/
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Granite City Food & Brewery
LICENSE #C-74411
#L-74412
Dear Clerk:
Enclosed is.a copy of a manager application for Jeffrey S. Buntger in connection with Granite City
- Food & Brewery located in Omaha.
Please present this application for manager to your CityNillage 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 t.l h say ink on recycled paper
• MANAGER APPLICATION office use
INSERT-FORM 3cRECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION OUT ] 2 2011
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRASKA LIQUOR
LINCOLN,NE 68509-5046 CONTROL COMMISSION
PHONE: (402)471-2571
FAX: (402)471-2814
Website: «,Vw.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 N p,
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
Corporationn/LLC information
Name of Corporation/LLC: G1(CL � C 1 o.X1&-fi fiAC,_roc
Premise information
Premise License Number: C/a J G 7Y5/11
(if new application leave blank)
Premise Trade Name/DBA: (Vc1Uir t 1 Pet) .pt f71'ewziv /
Premise Street Address: /O b/ /Y /0.7,J ef* e/
City: Qjlvi aJ State: A V 6 Zip Code: e5(/
Premise Phone Number: 4'a2 pea — 3--000
The individual whose name is listed as a poroorJe officer or man gins member as reported on insert form 3a
r3 m i h irn e
/ CORPORA OFFICER/MANAGING MEMBER SIGNATURE
(Faxed signatures are acceptable)
v�m 103
I /2011
2 of
III I II 1
1100017896
• Manager's information must be completed below PLEASE PRINT CLEARLY
Gender: MALE ❑ FEMALE /
Last Name: 13W.`� First Name: TC- y MI: S.
Home Address(include PO Box if applicable): &'13 /V: yY $ rre 7o
City: 4 ,'ri c oln County: /1/-g Zip Code: G $S a.9
Home Phone Number: zf i.2-4/)• 7 C 74 Business Phone Number: 3 513-S&d 0
Social Security Number: _ ,_.' Drivers License Number&State: /l/� _
Date Of Birth:� Place Of Birth: 6,14 6ic,J, yver
-
Are you married? If yes,complete spouse's information(Even if a spousal affidavit has been submitted)cit</ES ❑NO
Spouse's'information
- Spouses Last Name: Bit1-1'41--r1 First Name: -JackIy MI: /14
Social Security Number: Drivers License Number&State:/l/E
/
Date.Of Birth: Place Of Birth: Sr-le y .Z )
APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS .
APPLICANT SPOUSE
CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
3'43 "i/ S/*Mt S{-evk ~Per S. /d fs. .3fi•r a><
'7 i.o h /Vr 144 Lu,w44r4 _ /VC ,..00`f .106 C
6231 /V L• - //4 „ZJ/3" S• .2.1...1 Ski-reA
/{'CC A4 a 4 Y<5 t 0/$ /o/7 L:,co jki ,v(c.' 2.003 p2oro y
‘3/9 N' 04.., ,4ve. 7/3 /3 SA-Et P
l' 6 A A,fv 4 Vi si ?co? Po 4.,_iv% mob.)- 3
�/3�..c S, TY fer ,�dl S'Y/ cc. / / 8 cS-/. �i � �.
.ate. (p �2 L / �� ,ii+G.C:1691, d� Form103
W/ , 1", L.
"Po' �� Rev 1/2011
Page 3 of S
• MANAGER'S LAST TWO EMOLOYERS
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
g2C0 r eb...e„ti- 6/`andC C0+7 6". e ..�44.er3 7(03 -6 SG,,7i7 (/
doo L ,Zm 6 Et-e ei, 64c44 4.44. ..,"G L e.7.,.ke Ya.7. - Y 7'7 -03 so
MANAGER AND SPOUSE MUST REVIEW AND ANSWER THE QUESTIONS BELOW
Please print 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
•. l es by each individual's name.
i YES ❑ NO
If yes,please explain below or attach a separate page.
Name of Applicant Date of Where Description of Charge Disposition
Conviction Convicted
(nun/yyyy) (city&state) 47
.l
lJ. ` 7 �• a., Sr 7{I
Botr.: ti, ��Y/ o P00 r No VeP ide saJAI�e0440 ("chi ROO Xe
osam
• /1/ 300),,, ' A,, • �W�J,,,,w•+4..G hold 1P/"0�7 � ,, L
2. Have you or your spouse ever been approved .r ► ade application for a liquor license in Nebraska or
any other state? DYES ►` 0
IF YES,list the name of the premise.
3. Do you,as a manager, qualify under Nebraska Liquor Conte 1 Act(§53-131.01)and do you intend to
supervise,in person,the management of the business? iv,: S ❑NO
4. Have you enclosed the required fingerprint cards and PROPER FEES with this application?
Ch k or money order made payable to the Nebraska State Patrol for$38.00 per person)
W
ES ONO
RECEIVED ED Form103
Rev 1 2 11
Page 4 of 5
OCT 122011
NEBRASKA LIQUOR
CONTROL COMMISSION
� - ! .i J• (."_�." � i ¢t,`C � °. �'y H y 3'.'7 p e •( 4 �,b � !�d'� tih n a
)J ))'C ( p )Y rq Yt�7 ! i 4 ( }Juan 'I 3 qt1 1.• {�p� s V " iM 11
5 19 1f q�•m�[ ��{ a! V;.. lA p{ g" .P Vy � �3 a� t\S 1D�1�11� W 4! �1Y 71 4l R 7lnY }�jy it t J J N
pnml ? � '�9 M +A: �J S 1 !C <lu 1. d6o. yU� 1
�_ �a _ it •fifi �.
Fra Y ii !',f 1 w
.. ..,7:. t. .t„„�.rrniM1d. � 1 x . •:a�?ar�e� lug• � .a ,,.r. a��'�.Pcs!i•c •,lu .,.�,t�"'4�w'• ,i ,t
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.
•
ignature of Manager Applicant ature f Spouse
•
ACKNOWLEDGEMENT
State of Nebraska
County of L.by e � . � The foregoing instrument was acknowledged before me this
C) ), "1 )an 1 by Tie sr-Frey 6 u vl -0`,4- JG.e. k 1 v IA
date namelbfperson acknowledged i7 v +ra
Affix Seal
Notary Public signature - GENERAI.NOTARY•SlateofNebraska
THOMAS A. MONROE
My Comm.Exp.Sept.7,2014
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.
RECEIVED
Form t 03
OCT ' 2a'1 Pagel5of5
NEB 2A��CA LIQUOR
CONTROL COMMISSION
SPOUSAL AFFIDAVIT OF office use RECEIVED
NON PARTICIPATION INSERT
NEBRASKA LIQUOR CONTROL COMMISSION
• 301 CENTENNIAL MALL SOUTH O C T y 2 2011
PO BOX 95046
LINCOLPHONE:N,NE 71-255046 NEBRASKA LIQUOR
PHONE:(402)471-2571
FAX:(402)471-2814 CONTROL COMMISSION
Wcbsitc: www.lec.nv.gov
I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any
interest,directly or indirectly in the operation or profit of the business(§53-125(13))of the Liquor Control Act. I will not
tend bar,make sales,serve patrons,stock shelves,write checks,sign invoices or represent myself as the owner or in any
way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be
required;however,I am obligated to sign and disclose any information on all applications needed to process this
application.
•
i attire of spouse asking for waiver Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of �C:a,c'. .r>..
County of \—c-_`'Zc t'' The foregoing instrument was acknowledged before me this
' by ae— 1 y M S v
date i name of person acknowledged
Affix Seal
istitbIGENIERAL NOTARY•Se of
Notary Public signature THAS A.OM tat
MONROEka
My Comm.6xp.Sept.7,2014
I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for
compliance with the conditions set out above. If it is determined that the above individual has violated(§53-125(1.3))the
Commission may cancel or revoke the liquor license.
a( 2_
ttire of individual involved with application Printed name of applying individu
(Spouse of individual listed above)
State of K)Q._
County of Vl_ The foregoing instrument was acknowledged before me this
`'1n l by Tse .
date flank of person ac owle l c"
Affix Seal Gj (,NOj�l• of Nebraska
�� pril THOMAS A. MONROE
Notary Public signature *coma.Exr. ..7s°C.7 2Ol
In compliance with the ADA,this spousal affidavit of non participation is available in other formate for persona with disabilities.
A ten day advance period is requested in writing to produce the alternate ante format.
FORM 35-4178
Revisal 1l2008
persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
RECEIVED
Form t 03
OCT ' 2a'1 Pagel5of5
NEB 2A��CA LIQUOR
CONTROL COMMISSION
OA�YA R'�
City of Omaha, Nebraska flp
O-
C.)A -jo../1111111111k7
1819 Farnam -Suite LC 1 :�rhl• - �
Omaha, Nebraska 68183-0112 0 " .,`
Buster Brown .o �"
(402) 444-5550
City Clerk FAX (402) 444-5263 o!Q FE13
R9-
November 8, 2011
Granite City Food & Brewery, Ltd Application to appoint.Jeffrey S. Buntgen
Dba"Granite City Food & Brewery" manager of your present Class "C"
1001 North 102° Street Liquor License location
Omaha,NE 68114
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 22, 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
I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for
compliance with the conditions set out above. If it is determined that the above individual has violated(§53-125(1.3))the
Commission may cancel or revoke the liquor license.
a( 2_
ttire of individual involved with application Printed name of applying individu
(Spouse of individual listed above)
State of K)Q._
County of Vl_ The foregoing instrument was acknowledged before me this
`'1n l by Tse .
date flank of person ac owle l c"
Affix Seal Gj (,NOj�l• of Nebraska
�� pril THOMAS A. MONROE
Notary Public signature *coma.Exr. ..7s°C.7 2Ol
In compliance with the ADA,this spousal affidavit of non participation is available in other formate for persona with disabilities.
A ten day advance period is requested in writing to produce the alternate ante format.
FORM 35-4178
Revisal 1l2008
persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
RECEIVED
Form t 03
OCT ' 2a'1 Pagel5of5
NEB 2A��CA LIQUOR
CONTROL COMMISSION
• lirp4ti
City of Omaha, We6raskg A
tit
1819 Farnam—Suite LC 1 r.
Au( 1, `.*?
Omaha, Nebraska 68183-0112 0. _a �
Buster Brown (402) 444-5550 11
City Clerk FAX (402) 444-5263 4''TED BR�t►4`
November 8, 2011
Jeffrey S. Buntgen Application to be appointed manager of the present
343 North 44th Street#720 Class "C" Liquor License for Granite City Food &
Lincoln, NE 68503 Brewery, Ltd, dba"Granite City Food & Brewery",
1001 North 102nd Street, Omaha,NE
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 22, 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,
J,n.) /
Buster Brown
City Clerk
BJB:clj .
I am the spouse of the above listed individual. I understand that my spouse and I are responsible for
compliance with the conditions set out above. If it is determined that the above individual has violated(§53-125(1.3))the
Commission may cancel or revoke the liquor license.
a( 2_
ttire of individual involved with application Printed name of applying individu
(Spouse of individual listed above)
State of K)Q._
County of Vl_ The foregoing instrument was acknowledged before me this
`'1n l by Tse .
date flank of person ac owle l c"
Affix Seal Gj (,NOj�l• of Nebraska
�� pril THOMAS A. MONROE
Notary Public signature *coma.Exr. ..7s°C.7 2Ol
In compliance with the ADA,this spousal affidavit of non participation is available in other formate for persona with disabilities.
A ten day advance period is requested in writing to produce the alternate ante format.
FORM 35-4178
Revisal 1l2008
persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
RECEIVED
Form t 03
OCT ' 2a'1 Pagel5of5
NEB 2A��CA LIQUOR
CONTROL COMMISSION
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