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RES 2021-0007 - Appoint Alan J Jarecki manager of Immanuel Retirement Communities E-MAILED TO NLCC 1 ‘3•. c1 d �.,,ef .vot ST4)EN,,,, e.': '( I STATE OF NEBRASKA .'.4 , " x , Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION \ ;� Governor Hobert B.Rupe Executive Director + '44ctt s.°,��� 301 Centennial Mall South,5th 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/ January 4, 2021 To: CITY CLERK OF Omaha Email: carman.johnson@cityofomaha.org elizabeth.butler@cityofomaha.org. kimberly.pulliam@cityofomaha.org Manager Name: Jarecki, Alan J ' Licensee Name: IRC II, Inc Licensee Trade Name (DBA): The Arboretum License Number: 1122847 Date Due: January 19, 2020 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.frontdeskna nebraska.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: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) - . 21D1 /40 2v2.17 woo tA_u . al aw/ . , Clerk Signature: Date: 1 ' I J—i1 BR Janice M.Wiebusch Bruce Bailey Harry Hoch Commissioner Chairman Commissioner / Equal Opportunity Employer completed application to the Liquor Control Commission**** Trade Name Homewood Suites Omaha Name of Person Bein Fingerprinted: Joshua Houston Date of Birth: Last 4 SSN: Date fingerprints were taken: 11/23/2020 Location where fingerprints were taken: NSP 4411$1O8th St.Omaha,NE 68127 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 MANAGER APPLICATION Office use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION NOV1 $ Za2Li 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE68509.5046 NEBRASKA LIQUOR PHONE:(402)471-2571 CONTROL COMMISSION FAX:(402)47l-2814 Website: www.Icc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: �(, Complete all sections of the application. Be sure it is signed by a member or corporate officers corporate officer or member must be an individual on file with the Liquor Control Commission JFingerprints are required. See form 147 for further information,read form carefully to avoid delays in processing,this form MUST be included with your application. J. Provide a copy of one of the following: US birth certificate, naturalization papers or current US passport(even if you have provided this before) J• 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- participating spouse completes the top half;the manager completes the bottom half. Be sure to 0( complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business, the spouse must: • Sign the application • 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. • 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 2000011703 — `P� Form 103 `T Rev July 2018 d io` Page 1of6 7 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 MANAGER APPLICATION Office t'se INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NOV 1 8 7020 PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 • FAX:(402)471-2814 CONTROL COMMISSION Website:www.lcc.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: IRC II, Inc. Premise information Liquor License Number: 122847 Class Type ' (if new application leave blank) Premise Trade Name/DBA:The Arboretum Premise Street Address:8141 Farnam Drive City: Omaha County: Douglas Zip Code:68114 Premise Phone Number: (4O2) 39 -7573 Premise Email address: Pdaly@immanuel.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. SIGNATURE REQUIRED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 201$ Page 2 of 6 information, read form carefully to avoid delays in processing,this form MUST be included with your application. • 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 2000011703 — `P� Form 103 `T Rev July 2018 d io` Page 1of6 7 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 Manager's information must be completed below PLEASE PRINT CLEARLY Jarecki Alan Mt. Last Name: First Name: Home Address:782'1 Eaglewood Lane City: Arlington _ — county:Washington Zip Code:68002 Home Phone Number:(402)74 1-0067 Driver's License Number& State: - Social Security Number:__ Date Of Birth: Place Of Birth: Columbus, Nebraska _ Email address:ajarecki©immanuel.conl Are you married?If yes,complete spouse's information(Even if a spousal affidavit has been submitted) ❑YES QQ NO Spouse's information Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number& State: _- Date Of Birth: Place Of Birth: 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 Arlington, Nebraska 2020 Present Albion, Nebraska 2010 2010 Elkhorn, Nebraska 2015 ;2020 Hebron, Nebraska 12014 1.2015 Elkhorn, Nebraska '2011 12014 1 1 a Form 103 Rev July 2018 Page 3of6 ized officers or members search your license information here. SIGNATURE REQUIRED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 201$ Page 2 of 6 information, read form carefully to avoid delays in processing,this form MUST be included with your application. • 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 2000011703 — `P� Form 103 `T Rev July 2018 d io` Page 1of6 7 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 MANAGER'S LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 2017 Present Immanuel Gommunities,Eric Gurley 402-507-4899 12015 2017 LifeLoop LLC ;Amy Johnson 402-720-6415 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 as 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. x❑ YES ❑ NO If yes,please explain below or attach a separate page. Date of Where Description Name of Applicant Conviction Convicted of Disposition (mmlyyyy) (City&State) Charge J 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES ©NO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(553-131.01) and do you intend to supervise, in person,the management of the business? OYES ONO Form 103 Rev July 2018 Page 4 of 6 (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 2000011703 — `P� Form 103 `T Rev July 2018 d io` Page 1of6 7 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 4. List the alcohol related training and/or experience(when and where)of the person making application. R13-0132073 s INKA132914 Alan Joseph Jarecki *NLCC Training Certificate Issued: Name on Certificate: Applicant Name Date Name of program(attach copy of course completion ( YYYY) certificate) Alan Joseph Jarecki 11/2020 Responsible Beverage Service Training of Nebraska Alan Joseph Jarecki 11/2020 Lincoln City Alcohol Permit *For list of NLCC Certified Training Programs see training I:xperience: Applicant Name/Job Title Date of Name&Location of Business: Employment: Alan Jarecki.GM of Culinary Services October 2020 to Present Immanuel Communities, Omaha, Nebraska Alan Jarecki,Otreaor of Oeveiopmenl&Slrategfc Protects June 2017 to October 2020 Immanuel Communities, Omaha,Nebraska Alan Jarecki,Director of Operations August 2015 to May tot 7 LifeLoop, LLC, Omaha, Nebraska Alan Jarecki,CEO +roemberZJta+naupvar2615 Slue Valley Lutheran Homes I LTC Midwest,LLC,Hebron, Nebraska Alan Jarecki,COO Jur.c70i toStev.420,NI 4 Good Shepherd Lutheran Community, Blair, Nebraska 5. Have you enclosed form 147 regarding fingerprints? DYES ONO • Form 103 Rev July 2018 Page 5 of 6 your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES ©NO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(553-131.01) and do you intend to supervise, in person,the management of the business? OYES ONO Form 103 Rev July 2018 Page 4 of 6 (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 2000011703 — `P� Form 103 `T Rev July 2018 d io` Page 1of6 7 How was payment made to NSP? NSP PAYPORT ❑CASH El CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous applic.v,io iss than - . s ago? YES El 1� SIG , • li REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 OM/ Al I(,in-m o produce the alternate format. FORM 116 • REV NOV 2016 Page I 1 of 4 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 identification record are set forth in Title 28, CFR, 16.34. 51144 o"I", AL/A-XL-LC ,.-- S nature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of bt«jia The foregoing instrument was acknowledged before me this • A L'1.(-it - /7, ,)6 O by em Sareciel OF PERSON BEING ACKNOWLEDGED dn�c NAME L/ , (IU.Llf _ 4fi.eniAffix Scat NotaryPublic signature GENERAL MICHELE.1.NOTARY•State ofSHONKA Nebraska hly Comm.Exp.Sept.6,202I 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 2016 Page I 1 of 4 PRIVACY ACT STATEMENT/ SUBMISSION OF FINGERPRINTS/ RECEIVE' PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION i,`.' ). 8 2020 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRASKA LIQUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE: (402)47 I-2571 FAX: (402)47 1-2814 Wchsitc www Icc.ncbraska.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 S45.25 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 12t 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 with1our completed application to the Liquor Control Commission**** Trade Name Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: MEM Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? BNSP PAYPORT € 1CASH ❑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 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 1/4/2021 Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING Gmail Carman Johnson (CCIk) <carman. ohnson cit ofomaha.or > MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 1 message Carman Johnson (CCIk) Mon, Jan 4, 2021 at 12:19 <Carman.Johnson@cityofomaha.org> PM To: AJARECKI@immanuel.com, "Kuenning, Adam" <AKUENNING@immanuel.com> Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <Kimberly.Hoesing@cityofomaha.org> good afternoon RE: IRC II, INC & IMMANUEL RETIREMENT COMMUNITIES (2 LOCATIONS) • The Omaha City Clerk's Office has received your application from the Nebraska Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, JANUARY 12, 2021. City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. I ALSO NEED THE DATE OF BIRTH FOR ALAN J. JARECKI, PLEASE SEND ME THIS INFORMATION AS SOON AS POSSIBLE. Please notify me if you have any questions. • Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 https://mai I.google.com/mail/u/0?ik=cd387c45eb&view=pt&search=a II&permthid=thread-a%3Ar-159799509673326752%7Cmsg-a%3Ar-13299834424... 1/2 f 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 with1our completed application to the Liquor Control Commission**** Trade Name Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: MEM Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? BNSP PAYPORT € 1CASH ❑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 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 1/4/2021 Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 402-444-5263 fax Carman.johnson@cityofomaha.org • https://mai I.google.com/mail/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-159799509673326752%7Cmsg-a%3Ar-13299834424... 2/2 City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax Carman.johnson@cityofomaha.org https://mai I.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-1202114676099378045%7Cmsg-a%3Ar85865329799... 2/2 A�..e G..F 1. E-MAILED TO NLCC -- - S7"A j:Nt :; . . STATE OF NEBRASKA 64 ; '. Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION x Governor Hobert B.Rupe Executive Director ,,'Cif 1.r, 301 Centennial Mall South,5's 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.lec.nebraska.gov/ January 4,2021 To: CITY CLERK OF Omaha Email: • carman.johnson@cityofomaha.org elizabeth.butler@cityofomaha.org kimberly.pulliam@cityofomaha.org Manager Name: Jarecki, Alan J Licensee Name: • Immanuel Retirement Communities Licensee Trade Name (DBA): Pacific Springs Village akeside Village License Number: 1123653 & 1122961 Date Due: January 19, 2020 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.frontdesk( nebraska.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: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) �U , '-2D21.— DDD1 c, L.?�2c/e,V • Clerk Signature: C_-� Date: ` I J ZO-Li BR Janice M.Wiebusch Bruce Bailey Harry Hoch Commissioner Chairman Commissioner • An Equal Opportunity Employer quor Control Commission**** Trade Name Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: MEM Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? BNSP PAYPORT € 1CASH ❑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 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 MANAGER APPLICATION Office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION NOVg 2020 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 CONTROL COMMISSION FAX:(402)471-2814 Website:www.lcc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: do 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 O 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. �• Provide a copy of one of the following: US birth certificate, naturalization papers or current US passport (even if you have provided this before) i• 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- Olt participating spouse completes the top half; the manager completes the bottom half. Be sure to iJ complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business, the spouse must: • Sign the application • 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. • 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 2000011701 Form 103 Rev July 2018 © \(� Page 1 of 6 y fingerprints are already on file with the commission — fingerprints completed for a previous application less than 2 years ago? YES 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 MANAGER APPLICATION Office Use INSERT- FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NOV 1 8 2020 PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-257 1 FAX:(402)471-2814 CONTROL COMMISSION 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 Cotporatiott/LLC:Immanuel Retirement Communities Premise information Liquor License Number: 122961 Class Type Of new application leave blank) Premise Trade NameiDBA:Lakeside Village Premise Street Address:17475 Frances St. City: County:County: Douglas Zip Code:68130 Premise Phone Number: (402) 829-9020 Premise Email address: pdaly@lmmanUel.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. SIGNATURE REQUIRED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 2018 Page 2 of read form carefully to avoid delays in processing, this form MUST be included with your application. • 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 2000011701 Form 103 Rev July 2018 © \(� Page 1 of 6 y fingerprints are already on file with the commission — fingerprints completed for a previous application less than 2 years ago? YES 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: Jarecki First Name: Alan MI:J Home Address:7821 Eaglewood Lane City: Arlington _ county:Washington Zip Code:68002 Home Phone Number:(402)74 1-0067 Driver's License Number&State: _ Social Security Number:_ Date Of Birth: Place Of Birth: Columbus, Nebraska Email address:ajarecki@immanuel.com Are you married? If yes,complete spouse's information(Even if a spousal affidavit has been submitted) ❑YES Q NO Spouse's information Spouses Last Name: __ First Name: MI: Social Security Number: — Driver's License Number& State: Date Of Birth: Place Of Birth: APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS APPLICANT SPOUSE ` w YEAR YEAR YEAR YEAR CITY&STATE CITY&STATE FROM TO I FROM TO Arlington, Nebraska 2020 PresentlAlbion, Nebraska 2010 2010 --4 Elkhorn, Nebraska 2015 2020 Hebron, Nebraska +2014 .2015 Elkhorn, Nebraska 2011 12014 1 1 Form 103 Rev July 2018 Page 3 of 6 listed with the Commission. To see authorized officers or members search your license information here. SIGNATURE REQUIRED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 2018 Page 2 of read form carefully to avoid delays in processing, this form MUST be included with your application. • 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 2000011701 Form 103 Rev July 2018 © \(� Page 1 of 6 y fingerprints are already on file with the commission — fingerprints completed for a previous application less than 2 years ago? YES 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 • MANAGER'S LAST TWO EMPLOYERS rYE AR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 2017 Present Immanuel Communities,Eric Gurley 402-507-4899 2015 2017 LifeLoop LLC krny Johnson 402-720-6415 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 y 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. 1 YES El NO If yes,please explain below or attach a separate page. T Date of Where Description Name of Applicant Conviction Convicted of Disposition (rnm/yyyy) ( City&State) Charge 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYES ■QNO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(03-131.01) and do you intend to supervise, in person,the management of the business? DYES FIND Form 103 Rev July 2018 Page 4 of 6 t (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 2000011701 Form 103 Rev July 2018 © \(� Page 1 of 6 y fingerprints are already on file with the commission — fingerprints completed for a previous application less than 2 years ago? YES 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 4. List the alcohol related training and/or experience(when and where)of the person making application. Re-01328:8 d V0(.0132914 Alan Joseph Jarecki *NLCC Training Certificate Issued: Name on Certificate: Applicant Name Date Name of program(attach copy of course completion ( yyyy) certificate) Alan Joseph Jarecki 11/2020 Responsible Beverage Service Training of Nebraska Alan Joseph Jarecki 11/2020 Lincoln City Alcohol Permit • *For list of NLCC Certified Training Programs sec training Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: Alan Jarecki.GM of Culinary Services Ocober 2020 to Present Immanuel Communities,Omaha, Nebraska Wan Jareekl,Otred0r of Development&Strategic Proiecs Jure 2017 to October 2020 Immanuel Communities.Omaha. Nebraska Alan Jarecki,Director of Operations August 2015 to May 2051 LifeLoop, LLC, Omaha, Nebraska Alan Jarecki,CEO s,,r.,„exu20Nro eusr2015 Blue Valley Lutheran Homes!LTC Midwest, LLC.Hebron, Nebraska Alan Jarecki,COO June 2or t re September 2014 Good Shepherd Lutheran Community, Blair, Nebraska 5. Have you enclosed form 147 regarding fingerprints? OYES ENO Form 103 Rev July 2018 Page 5 of 6 1 or made application for a liquor license in Nebraska or any other state? OYES ■QNO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(03-131.01) and do you intend to supervise, in person,the management of the business? DYES FIND Form 103 Rev July 2018 Page 4 of 6 t (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 2000011701 Form 103 Rev July 2018 © \(� Page 1 of 6 y fingerprints are already on file with the commission — fingerprints completed for a previous application less than 2 years ago? YES 0 SIG TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 sons 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 2016 Page I 1 of 4 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 identification record are set forth in Title 28, CFR, 16.34. S nature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of UL it The foregoing instrument was acknowledged before me this • Vt-ittlx"/" 17, J0 0. by f`lab� Sarecil dare NAME OF PERSON BEING ACKNOWLEDGED Vk L acid �% `L Affix Seal Notary Vublic signature GENERAL NOTARY•State of Nebraska MiCI-IELE J.SHONKA lq.,...jkz• My Comm.Exp.Sept.6,2021 • 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 Page 6 of 6 2016 Page I 1 of 4 PRIVACY ACT STATEMENT/ SUBMISSION OF FINGERPRINTS/ RECEIVED PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION ''i,'',` 1. 8 2020 301 CENTENNIAL MALL SOUTH • PO BOX 95046 NEBRASKA L IUUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE: (402)471-2571 • FAX: (402)47 1-2814 Wchsitc wwwv Icc.ncbraska.gcv 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 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 _ _ _ Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: _ Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 1/4/2021 • Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING Emil Carman Johnson (CCIk) <carman.johnson@cityofomaha.org> MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 1 message Carman Johnson (CCIk) Mon, Jan 4, 2021 at 12:19 <Carman.Johnson@cityofomaha.org> • PM To: AJARECKI@immanuel.com, "Kuenning, Adam" <AKUENNING@immanuel.com> Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <Kimberly.Hoesing@cityofomaha.org> good afternoon RE: RC II, INC & IMMANUEL RETIREMENT COMMUNITIES 2 LOCATIONS) The Omaha City Clerk's Office has received your application from the Nebraska Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, JANUARY 12, 2021. City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at • 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. I ALSO NEED THE DATE OF BIRTH FOR ALAN J. JARECKI, PLEASE SEND ME THIS INFORMATION AS SOON AS POSSIBLE. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 https://mail.google.com/mail/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-159799509673326752%7Cmsg-a%3Ar-13299834424... 1/2 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 _ _ _ Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: _ Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 1/4/2021 Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 402-444-5263 fax Carman.johnson@cityofomaha.org hops://mail.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-159799509673326752%7Cmsg-a%3Ar-13299834424... 2/2 2/2 City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax Carman.johnson@cityofomaha.org https://mai I.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-1202114676099378045%7Cmsg-a%3Ar85865329799... 2/2 A�..e G..F 1. E-MAILED TO NLCC3," 04 �_"liar 4e —; � STATE OF NEBRASKA ` " J m Pete Ricketts • NEBRASKA LIQUOR CONTROL COMMISSION Governor Hobert B.Rupe Executive Director Z 19t F 301 Centennial Mall South,5th 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/ January 4,2021 To: CITY CLERK OF Omaha Email: • carman.johnson@cityofomaha.org elizabeth.butler@cityofomaha.org kimberly.pulliam@cityofomaha.org • Manager Name: • Jarecki, Alan J Licensee Name: Immanuel Retirement Communities • Licensee Trade Name (DBA): Pacific Springs Village & Lakeside Village • License Number: 1123653 & 961 Date Due: January 19, 2020 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.frontdesk(c�nebraska.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: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) 20 , WZ) 'Waft • JC:0 tit w /.�l P2/ • • • Clerk Signature: Date: ' ! J" Z07,1 BR • • Janice M.Wiebusch t3ruce Bailey Harry Hoch Commissioner Chairman Commissioner An E,.tat Opportunity Employer oseph Jarecki Date of Birth: _ Last 4 SSN: Date fingerprints were taken: 11/05/2020 Location where fingerprints were taken: Lincoln, Nebraska How was payment made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 MANAGER APPLICATION Offi"usc RECEIVEDINSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION NOV 1 8 2020 301 CENTENNIAL MALL SO1 TH PO BOX 95046 NE LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 CONTROL COMMISSION FAX:(402)471-2814 Websile:www.lcc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: f• Complete all sections of the application. Be sure it is signed by a member or corporate officers corporate officer or member must be an individual on file with the Liquor Control Commission N• 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: US birth certificate, naturalization papers or current US passport(even if you have provided this before) si• 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- participating spouse completes the top half; the manager completes the bottom half. Be sure to 0( complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business,the spouse must: e • Sign the application V • 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. • 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 2000011704 — aaJ Cn Rev my 2O 8 ent made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 MANAGER APPLICATION Office t Ise INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NOV 1 8 2020 PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 NEBRASKA LIQUOR FAX: (402)471-2814 CONTROL COMMISSION 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 Corporation2LC: Immanuel Retirement Communities Premise information 123653 Liquor License Number: Class Type (if new applKatIon lave blank) Premise Trade Namer''DBA:Pacific Springs Village Premise Street Address:805 South 173rd Court City: Omaha County: Douglas Zip Code:68118 Premise Phone Number: (402) 704-3543 Premise Email address: pdaly p@i manuel.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. SIGNATURE REQUIRED BY CORPORATE OFFICER /MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 2018 Page 2 of 6 avoid delays in processing, this form MUST be included with your application. • 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 2000011704 — aaJ Cn Rev my 2O 8 ent made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: Jarecki First Name: Alan MI:`1 Home Address:7821 Eaglewood Lane City: Arlington County:Washington Zip Code:68002 Home Phone Number:(402)741-0067 Driver's License Number&State: Social Security Number:__._ Date Of Birth:1111111M Place Of Birth: Columbus, Nebraska Email address:ajareckl C immanuel.COm Are you married?If yes, complete spouse's information(Even if a spousal affidavit has been submitted) ❑YES ❑Q NO , Spouse's information Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number&State: _ Date Of Birth: Place Of Birth: APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN (10)YEARS APPLICANT SPOUSE CITY&STATEYER YEAR ' T CITY&STATE YEAR YEAR FROM TO FROM _ TO Arlington, Nebraska 2020 Present Albion, Nebraska 2010 2010 'Elkhorn, Nebraska 2015 2020 f Hebron, Nebraska !2014 2015 • Elkhorn, Nebraska '2011 12014 j Form 103 Rev July 2018 Page 3 of 6 ficer 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. SIGNATURE REQUIRED BY CORPORATE OFFICER /MANAGING MEMBER (Faxed signatures are acceptable) Form 103 Rev July 2018 Page 2 of 6 avoid delays in processing, this form MUST be included with your application. • 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 2000011704 — aaJ Cn Rev my 2O 8 ent made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 MANAGER'S LAST TWO EMPLOYERS YEAR TELEPHONE FROM TO NAME OF EMPLOYER } NAME OF SUPERVISOR NUMBER 2017 Present Immanuel Communities Eric Gurley 402-507-4899 12015 2017 LifeLoop LLC Amy Johnson 402-720-6415 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. J YES fl NO If yes,please explain below or attach a separate page. Date of ' Where Description Name of Applicant Conviction ►, Convicted of Disposition (mm/yyyy) , (City&State) Charge - a 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES QNO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(553-131.01) and do you intend to supervise, in person,the management of the business? DYES ONO Form 103 Rev July 2018 Page 4 of 6 f 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 2000011704 — aaJ Cn Rev my 2O 8 ent made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 4. List the alcohol related training and/or experience(when and where)of the person making application. R8-0152678&Li 0i32914 Alan Joseph Jarecki «NLCC Training Certificate Issued: Name on Certificate: Applicant Name Date Name of program(attach copy of course completion ( YYYY) certificate) Alan Joseph Jarecki 11/2020 Responsible Beverage Service Training of Nebraska Alan Joseph Jarecki 11/2020 Lincoln City Alcohol Permit ''For list of NLCC Certified Training Programs sec training 1:xperience: Applicant Name/Job Title Date of Name&Location of Business: Employment: Alan Jarecki.GM of Culinary Services aerobe,202o to Present Immanuel Communities,Omaha, Nebraska Nan Jared,i.Director of Development&Strategic Projects June 2017 to October 2020 Immanuel Communities,Omaha.Nebraska Alan Jarecki,Director of Operations August 2015 t0 May 20;7 LifeLoop, LLC,Omaha. Nebraska Alan Jarecki,CEO soeo oi2014toA.eus,2o,5 Blue Valley Lutheran Homes!LTC Midwest, LLC, Hebron.Nebraska Alan Jarecki,COO ;u a Zan ceSeptember 2014 Good Shepherd Lutheran Community, Blair, Nebraska 5. Have you enclosed form 147 regarding fingerprints? YES ONO lomi103 Rev July 2018 Page 5 of 6 - a 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES QNO IF YES, list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act(553-131.01) and do you intend to supervise, in person,the management of the business? DYES ONO Form 103 Rev July 2018 Page 4 of 6 f 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 2000011704 — aaJ Cn Rev my 2O 8 ent made to NSP? CiiNSP PAYPORT I ]CASH IICHECK SENT TO NSP CK# My fingerprints are already on file with the commission - fingerprints completed for a previous application less th...___ an 2 y(4....L ears ago? YES Fri4SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 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 identification record are set forth in Title 28, CFR, 16.34. ,--_' S nature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of bt UUC+k2 The foregoing instrument was acknowledged before me this `t 4cittL i-- /7, )o.� ? by F Ha41 Ja.i ecki -- dace NAME OF PERSON BEING ACKNOWLEDGED tilt,L dalle• 0u�rj 4 Affix Seat Notary blic signature, 0 GENERAL.MICHELE d.NOTARY•State o1SHO NebraskaNKA IT My Comm.tap.Sept.6,2021 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 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 PRIVACY ACT STATEMENT/ SUBMISSION OF FINGERPRINTS/ RECEIVED PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION is`.` Y 8 2020 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRASKA LIQUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE: (402)471-2571 FAX:(402)471-2814 1\\'chsiic www Icc.nchraska.iov 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.nso 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 NSF 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 withyouur completed application to the Liquor Control Commission**** Trade Name _ Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: Last 4 SSN:� Date fingerprints were taken: 11/_5/2020 Location where fingerprints were taken: Lincoln, Nebraska 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 ❑ SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 ing to produce the alternate format. Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 1/4/2021 Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING Carman Johnson (CCIk) <carman. ohnson cit ofomaha.or > Gmail i @ y g MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 1 message Carman Johnson (CCIk) Mon, Jan 4, 2021 at 12:19 <Carman.Johnson@cityofomaha.org> PM To: AJARECKI@immanuel.com, "Kuenning, Adam" <AKUENNING@immanuel.com> Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <Kimberly.Hoesing@cityofomaha.org> good afternoon RE: IRC II, INC & IMMANUEL RETIREMENT COMMUNITIES (2 LOCATIONS) The Omaha City Clerk's Office has received your application from the Nebraska Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, JANUARY 12, 2021. City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. I ALSO NEED THE DATE OF BIRTH FOR ALAN J. JARECKI, PLEASE SEND ME THIS INFORMATION AS SOON AS POSSIBLE. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 https://mai l.google.com/mail/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-159799509673326752%7Cmsg-a%3Ar-13299834424... 1/2 he 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 withyouur completed application to the Liquor Control Commission**** Trade Name _ Name of Person Being Fingerprinted: Alan Joseph Jarecki Date of Birth: Last 4 SSN:� Date fingerprints were taken: 11/_5/2020 Location where fingerprints were taken: Lincoln, Nebraska 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 ❑ SIG , TURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 ing to produce the alternate format. Form 103 Rev July 2018 Page 6 of 6 Page 6 of 6 Page 6 of 6 2016 Page I 1 of 4 1/4/2021 Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 402-444-5263 fax Carman.johnson@cityofomaha.org https://m ai I.google.co m/ma i I/u/0?ik=cd 387c45eb&view=pt&sea rch=a I I&permth i d=th read-a%3Ar-159799509673326752%7Cm sg-a%3Ar-13299834424... 2/2 Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax Carman.johnson@cityofomaha.org https://mai I.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-1202114676099378045%7Cmsg-a%3Ar85865329799... 2/2 A�..e G..F 1.