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RES 2020-1160 - Appoint Kristine L Maxey manager of Veterans FW 8334 ,,.,,.._,.»,>,,, E-MAILED TO NLCC/2/Ti -2,e ,7. ,:. sre , . g �' �� STATE OF.NEBRASKA • e ► l ,:;s/ Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION '�.d''M'sv ). x Hobert B.Rupe 44�'•�di:: +�"•��a Governor '411 'r 'e rr'' = Executive Director M4 44.- .. .,Qt,,i_ m w< ce,P^ 301 Centennial Mall South,5 Floor P.O.Box 95046 Lincoln,Nebraska,68509-5046 Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 TSR USER 800-833-7252(TTY) Web Address http://www.lcc.nebraska.gov/ November 23,2020 To: CITY CLERK OF Omaha • Email: carman.johnson@cityofomaha.org ' elizabeth.butler@cityofomaha.org • • kimberly.pulliam@cityofomaha.org Manager Name: Maxey, Kristine L Licensee Name: Veterans Herman Godberson 8334 Licensee Trade Name (DBA): Veterans F W 8334 License Number: C 010100 • • Date Due: January 7, 2021 I have attached a copy of a new corporate manager application that was submitted to the Nebraska Liquor Control Commission. Please complete the following information below to indicate your recommendation. Send back to Rebecca Roberts at Icc.frontdesknebraska.gov or fax to (402) 471 • - 2814. If you have questions concerning this matter, please contact our office at (402) 471-2572. • - APPROVED NO LOCAL RECOMMENDATION • DENIED • COMMENTS:nnIIn /- (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) . Ra-cS #1-02-1) 1 I Dere/14 hl* /.52(42., Clerk Signature: Date: ) 2—/L9 207.0 • BR • • Janice M.Wiebusch Bruce Bailey Harry Hoch Commissioner Chairman Commissioner An I•tual Opportunity Employer MANAGER APPLICATION Office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 NOV 2 3 202@ LINCOLN.NE 68509-5046 PHONE:(402)471-2571 NEBRASKA LIQUOR FAX:(402)471-2814 ! `',1 ,� COMMISSION W ebsite:www.1cc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MrjtNAGER MUST: J• Complete all sections of the application. Be sure it is signed by a member or corporate officer, corporate officer or member must be an individual on file with the Liquor Control Commission Fingerprints are required. See form 147 for further information,read form carefully to avoid delays in processing, this form MUST be included with your application. Ni Provide a copy of one of the following: US birth certificate, naturalization papers or current US passport (even if you have provided this before) Be a registered voter in the State of Nebraska, include a copy of voter card or print document from Secretary of State website with application Spouse who will not participate in the business, spouse must: • Complete the Spousal Affidavit of Non Participation Insert (must be notarized). The non- tparticipating spouse completes the top half; the manager completes the bottom half. Be sure to 0complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business, the spouse must: J. Sign the application vi Fingerprints are required. See form 147 for further information, read form carefully to avoid delays in processing, this form MUST be included with your application. I. Provide a copy of one of the following: birth certificate, naturalization papers or current US passport (even if you have provided this before) �• Be a registered voter in the state of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required 20000117@9 Form 103 Rev July 2018 Page I of 6 MANAGER APPLICATION Office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NOV 2 3 2020 PO BOX 95046 LINCOLN.NE 68509-5046 NEBRAS A LIQUOR PHONE: (402)471-2571 P, FAX:(402)471-2814 �sONTR0i. i�'. '.'Jl MISSION Website:www.icc.nebraska.gov MUST BE: ✓ Include copy of US birth certificate, naturalization paper or current US passport ✓ Nebraska resident. Include copy of voter registration card or print out document from Secretary of State website ✓ Fingerprinted. See form 147 for further information, read form carefully to avoid delays in processing, this form MUST be included with your application ✓ 21 years of age or older Corporation/LLC information Name of Corporation/LLC: Veterans Herman Godberson 8334 Premise information Liquor License Number: �''010100 Class Type (if new application leave blank) Premise Trade Name/DBA: V r V V Post 8334 Premise Street Address:5083 S 136 Street City:Omaha County:Douglas Zip Code:68137 • Premise Phone Number:402-895-5656 Premise Email address:vfw8334@yahoo.com 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. To see authorized officers or members search your license information here. L'-' 72- • SIGNAT REQUIRE Y ORPORATE OFFICER!MANAGING MEMBER ed signatures are acceptable) Form 103 Rev July 2018 Page 2 of 6 this form MUST be included with your application. I. Provide a copy of one of the following: birth certificate, naturalization papers or current US passport (even if you have provided this before) �• Be a registered voter in the state of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required 20000117@9 Form 103 Rev July 2018 Page I of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: Maxey First Name: Kristine MI: 1-- Home Address: 6123 S 178th Street City: Omaha Douglas County: Zip code:68135 Home Phone Number: n/a cell: 785-201 -8739 Driver's License Number& State: Social Security Number: Date Of Birth: Place Of Birth:Om a ha Email address: kmaxey70@gmail.com Are you married?If yes,complete spouse's information(Even if a spousal affidavit has been submitted). D YES ❑NO Spouse's information Spouses Last Name: Maxey First Name:J i m m i e MI: Social Security Number Driver's License Number& State. 11111.1111 Date Of Birth: Place Of Birth:Evansville, IN APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS APPLICANT SPOUSE CITY& STATE YEAR YEAR CITY & STATES YEAR FROM TO FROM TO Omaha, NE 2018 2020 Omaha, NE 2017 2020 Salina, KS 2009 2018 Salina, KS 2012 2017 Omaha, NE 2004 2012 Form 103 Rev July 2018 Page 3 of 6 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. To see authorized officers or members search your license information here. L'-' 72- • SIGNAT REQUIRE Y ORPORATE OFFICER!MANAGING MEMBER ed signatures are acceptable) Form 103 Rev July 2018 Page 2 of 6 this form MUST be included with your application. I. Provide a copy of one of the following: birth certificate, naturalization papers or current US passport (even if you have provided this before) �• Be a registered voter in the state of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required 20000117@9 Form 103 Rev July 2018 Page I of 6 MANAGER'S LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 2020 pres VFW Greg Kleve 402-850-3864 2019 2020 Hegg Companies Alan Clark 605-336-2111 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, 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, include traffic violations. Also list any charges pending at the time of this application. if more than one party, please list charges by each individual's name. Commission must be notified of any arrests and/or convictions that may occur after the date of signing this application. 0 YES El NO If yes, please explain below or attach a separate page. Date of Where Description Name of Applicant Conviction Convicted of Disposition (mm ) ( Cit &State) Charge ■ ■ ■ I ■ 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYES ONO IF YES, list the name of the premise(s): 3. Do you, as a manager, qualify under Nebraska Liquor Control Act (553-131.01 Z and do you intend to supervise, in person, the management of the business? ❑Q YES ENO Form 103 Rev July 2018 Page 4of6 �• Be a registered voter in the state of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required 20000117@9 Form 103 Rev July 2018 Page I of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued: Name on Certificate: Applicant Name (mrtDvatyYYY) Name of program (attach copy of course completion certificate) Kristine Maxey 11/7/2019 TRAINING FOR INTERVENTION PROCEDURES (TIPS) *For list of NLCC Certified Training Programs see training Experience: Date of Applicant Name/Job Title Employment: Name& Location of Business: Kristine Maxe/GM 2018-2020 Holiday Inn Express Omaha, NE 5. Have you enclosed form 147 regarding fingerprints? 'YES ONO Form 103 Rev July 2018 Page 5 of 6 • 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 fraudulent. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in FBI identification record. The procedures.for obtaining a change, correction, or updating an FBI ide tification record are set forth in Title 28, CFR, 16.34. Sign tore of Manager ppli t Si ore of Spouse ACKNOWLEDGEMENT State of Nebra County of , )U 9 f�} The foregoing instrument was acknowledged before me this q I��ou en'1 h pi- ,30 go by Uebra RA 04- dace NAME OF PERSON BEING ACKNOWLEDGED Affix Seal Notary Public signature 6BillA.NOTARY-Stabs ofNebraska DEBRA A BLUM ` Noomla.Exp.September 29,2t►24 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 July 2018 Page 6 of 6 PRIVACY ACT STATEMENT/ SUBMISSION OF FINGERPRINTS / RECEIVED PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION NOV 2 3 2020 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.nebraska.gov THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp Or a check made payable to NSP can be mailed directly to the following address: ***Please indicate on your payment who the payment is for(the name of the person being fingerprinted) and the payment is for a Liquor License*** The Nebraska State Patrol—CID Division 3800 NW 12th Street Lincoln, NE 68521 • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID Applicant(s) will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application. Applicant Notification and Record Challenge: Your fingerprints will he used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedures for obtaining a change, correction, or updating a FBI identification record are set forth in Title.28, CFR, 16.34. ****Please Submit this form with your completed application to the Liquor Control.Commission**** Trade Name Veterans Herman Godbeson 8334 Name of Person Bein Fingerprinted: Kristine Maxey Date of Birth: Last 4 SSN: Date fingerprints were taken: 11-18-2020 Location where fingerprints were taken: Douglas County Sheriff How was payment made to NSP? 8 NSP PAYPORT LICASH ❑CHECK SENT TO NSF CK# My fingerprints are already on file with the commission — fingerprints completed for a previous • applicatio less than 2 years ago? YES El SIGNATURE R QUIRED OF PERS N EING FINGERPRINTED FORM 147 REV AUG 2020 PRIVACY ACT STATEMENT/ SUBMISSION OF FINGERPRINTS / RECEIV ED PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION NOV 2 33 02] 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBPP. : . LIOU:R LINCOLN, NE 68509-5046 CONTROL COMMISSION PHONE: (402)471-2571 FAX: (402)471-2814 Website: www.lcc.nebraska.gov THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp Or a check made payable to NSP can be mailed directly to the following address: ***Please indicate on your payment who the payment is for(the name of the person being fingerprinted) and the payment is for a Liquor License*** The Nebraska State Patrol—CID Division 3800 NW 12`1' Street Lincoln, NE 68521 • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID Applicant(s) will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedures for obtaining a change, correction, or updating a FBI identification record are set.forth in Title 28, CFR, 16.34. ****Please Submit this form with your completed application to the Liquor Control Commission**** Trade Name Veterans Herman Godbeson 8334 Name of Person Being Fingerprinted: Jimmie Maxey Date of Birth: 11111111.1111 Last 4 SSN: Date fingerprints were taken: 11-18-2020 Location where fingerprints were taken: Douglas County Sheriff How was payment made to NSP? ®NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK # My fingerprints are already on file with the commission —fingerprints completed for a previous application less than 2 years ago? YES ❑ • T REQU OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020