RES 2009-0657 - Appoint Jeffrey K Rothlisberger manager of Omaha Keno King ° N'o; L t�, lVL-. •L� nrr1rrrn
STATE.OF NEBRASKA
r
�w`. � u yr'�i DAve pjn mat NEBRASKA LIQUOR CONTROL COMMISSION
" 09 JUG —�# RN 8: 3 2 Hobert B. Rupe
t� i, T �.- N Governor P
4t• y •_.j.. _.. ., . Executive Director
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CITY C1•� 301 Centennial Mall South,5th Floor
�E.�P,K
CITY CLERK P.O.Box95046
l� NFBRASKA
OMAHA. 1�E[i Q S K/ Lincoln,Nebraska 68509-5046
Phone(402)471-2571
June 2, 2009 • Fax(402)471-2814
TRS USER 800 833-7352(IT1')
web address:http://wunv.lcc.ne.gov/
OMAHA CITY CLERK
1819 FARNAM FC-1 •
OMAHA NE 68183
RE: CLAIBORNE CENTRE, LLC
DBA: OMAHA KENO KING
LICENSE #I 74767
Dear Clerk: • •
Enclosed is a copy of a manager application for Jeffrey K Rothlisberger in connection with Omaha
Keno King, located at 6553 Ames Ave in Omaha. ,
Please present this application for manager to your City/Village Council or County
Commissioners and send us the results of their action.
•
Sincerely,
"4114
Lyn . ake •
Licensing Division
NEBRASKA LIQUOR CONTROL COMMISSION
encl.
cc: file
Rhonda R.Flower Bob Logsdon Robert Batt
Commissioner Chairman Comm issoner
An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
°"MM4AGER APPLICATION Office Use
INSERT•FORM 3c RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046 J U N 1 2009
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.ne.eov NEBRASKA LIQUOR
CONTROL rnMMiSSION
Corporate manager,including spouse,are required to adhere to the following requirements
If spouse filed affidavit of non-participation fingerprints and proof of citizenship not required
1) Must be a citizen of the United States
2) Must be a Nebraska resident(Chapter 2—006)
3) Must provide a copy of birth certificate,naturalization paper or US passport j r
4) Must submit fingerprints(2 cards per person) 1t/
5) Must be 21 years of age or older
6) Applicant may be required to take a training course
Name of Corporation/LLC: (,I Oil-Wm-6, ti#iL, Ce (
Premise License Number: 7ff 7 '7
(if new application leave blank)
Premise Trade Name/DBA: Oyh.gi. 12t.n 1)
Premise Street Address: LP AyYl2 A•
•
I" D
City: EinkithIA- t Zip Code: L 'i b
Premise Phone Number: 4/67-' "t (— 5-i `o L1
CORPORATE OFFICER SIGNATURE
Faxed si: !attires are acce stable
1111111111111111111111111111
0900010348
Form 3c "`
----------—
ortunity/Affirmative Action Employer
Printed with soy ink on recycled paper
Gender: .,'A MALE ❑FEMALE
Last Name: 4R 0+lit L i S '✓�- First Name:\k-Pfra
Home Address(include PO Box if applicable): 412 (QV0 {b 1' -e-
City: Pf CLI i� o AY State: ht,, Zip Code: /00DdJ
Home Phone Number: 41114106 401V l° Business Phone Number: `C D2( 3`t"—s--g--7 0
Social Security Number:_ •�Drivers License Number&State: f,
Date Of Birth: _ Place Of Birth: LO &L..&1, l ,
yirES ❑NO
Spouses Last Name: k'U S First Name: in4/L-x MI:
Social Security Number: _Drivers License Number&State;
Date Of Birth: _ Place Of Birth: 1 " w
CITY&STATE YEAR CITY&STATE YEAR
FROM TO FROM TO
lei D . Kt, 'Oq M
11111111
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
it ' s old. ffef €
Form 3c Page 2
•
1. READ PARAGRAPH CAREFULLY AND ANSWER COMPLETELY AND ACCURATELY.
Has anyone who is a party to this application, or their spouse,EVER been onvicted of or plead guilty
to any charge. Charge means any charge alleging a felony,misdemeanor, 'iolation of a federal or state
law; a violation of a local law, ordinance or resolution. List the nature of a charge,where the charge
occurred and the year and month of the conviction or plea. Also list any charges pending at the time of
this application. If more than one party.Please list charges by each indvidual's n me.
OYES Xj .0 If yes,please explain below or attach a separ4te page.
ECEIVED
JUN 1 20U ;
NEBRASKA LIQUOR
CONTROL COMMISSION
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other
state? IF YES,list the name of the premise.
•
YES NO. t l41-1 P)b Deft �'`,G � L-1-e
3. Do you, as a manager,have all the qualifications required to hold a Nebraska Liquor License? Nebraska
Liquor Control Act 053-131.01)
YES ONO
4. Have you filed the required fingerprint cards and PROPER FEES with th's application? (The check or money
order must be made out to the Nebraska State Patrol for$38.00 per...per. n)_,, .
krYES ENO
5. Do you have any experience in selling alcohol in the State of Nebraska?
If so list training and/or experience (when and where)
Date: Where:
9awbier/e/ UY2-'
L A
Form 3c Page 3
•
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.
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. .
•
aflitutabo
0
X1A—
/tur anager Applicant Signature of Spouse.
State of Nebraska .
County of County of QKSIkf
The foregoing,, p
instrument
was acknowledged before The forego instrument was acknowledged before
me this ore' "`d__ Q f y by me this 9l /i1,7 74A99 by .• •
Met . 4. '
Notary Publl ignature • Notary Pubii ignature
•
Affix Seal He Affix Sear Here
di GENERAL NOTARYM• Nebraska • .
MON NOHNER WENERAL NOTARY•Stete of Nebraska
My Comte.Exp.May 31,2010 1MIGUEi C NUNO •
MI Comm.Exp.April 10,2012
•
•
In compliance with the ADA,this manager insert form 3c•is available in other formats for persona with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
•
Form 3c ' Page 4
otANHA, ,,
City of Omaha, fAlebraskg 4,,agriti )•-t
s�
1819 Farnam—Suite LC 1 z �4" � !�� ,,_ ,
Omaha, Nebraska 68183-0112 0® -�a, � �'
Buster Brown (402) 444-5550 .o )
City Clerk FAX (402) 444-5263 oR aR
FE ‘ 4
•
June 9, 2009
Claiborne Centre, LLC. Application to appoint Jefferey K.
Dba "Omaha Keno King" Rothlisberger manager of your present
6553 Ames Avenue Class"I" Liquor License
Omaha, NE 68104 •
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application to appoint a manager to the liquor license has been set for June 23, 2009
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,
41
Buster Brown
City Clerk
BJB:clj
instrument
was acknowledged before The forego instrument was acknowledged before
me this ore' "`d__ Q f y by me this 9l /i1,7 74A99 by .• •
Met . 4. '
Notary Publl ignature • Notary Pubii ignature
•
Affix Seal He Affix Sear Here
di GENERAL NOTARYM• Nebraska • .
MON NOHNER WENERAL NOTARY•Stete of Nebraska
My Comte.Exp.May 31,2010 1MIGUEi C NUNO •
MI Comm.Exp.April 10,2012
•
•
In compliance with the ADA,this manager insert form 3c•is available in other formats for persona with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
•
Form 3c ' Page 4
�MAHA k .
o Omaha .zebras aCity I8,
rfr#4161Cial
1819 Farnam Suite LC 1
Omaha, Nebraska 68183-0112 0® '' '
Buster Brown (402) 444-5550 .o •
City Clerk FAX (402) 444-5263 o�44'D FEBRvt.i•
June 9, 2009
Jeffrey K. Rothlisberger Applications to be appointed manager of the present
9260 Co Rd 36 Class "I" Liquor Licenses for Claiborne Centre, LLC,
Ft. Calhoun,NE 68023 dba"Omaha Keno King", 6553 Ames Avenue, 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 June 23,
2009. 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
41
Buster Brown
City Clerk
BJB:clj
instrument
was acknowledged before The forego instrument was acknowledged before
me this ore' "`d__ Q f y by me this 9l /i1,7 74A99 by .• •
Met . 4. '
Notary Publl ignature • Notary Pubii ignature
•
Affix Seal He Affix Sear Here
di GENERAL NOTARYM• Nebraska • .
MON NOHNER WENERAL NOTARY•Stete of Nebraska
My Comte.Exp.May 31,2010 1MIGUEi C NUNO •
MI Comm.Exp.April 10,2012
•
•
In compliance with the ADA,this manager insert form 3c•is available in other formats for persona with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Revised 9/2008
•
Form 3c ' Page 4
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First Name: in4/L-x MI:
Social Security Number: _Drivers License Number&State;
Date Of Birth: _ Place Of Birth: 1 " w
CITY&STATE YEAR CITY&STATE YEAR
FROM TO FROM TO
lei D . Kt, 'Oq M
11111111
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
it ' s old. ffef €
Form 3c Page 2