RES 2006-1128 - Appoint Becky Borosko manager of Kum & Go #351 p^- STATE OF NEBRASKA
4\a, ��`44 ,,.t.V;t Dave Heineman /� k F NEBRASKA LIQUOR CONTROL COMMISSION
VA_ ItoWN Governor uo SEP 1 3 g, p j Hobert B. Rupe
t r�9R,:j......:86�_= C Ail U W
Executive Director
C t i' p �,i 301 Centennial Mall South,5th Floor
l i`u L• k k P.O.Box 95046
` R ` Lincoln,Nebraska 68509-5046
t... �� Phone(402)471-2571
Fax(402)471-2814
TRS USER 800 833-7352(TTY)
web address:http://www.lcc.ne.gov/
September 11, 2006
Omaha City Clerk
1819 Farnam Street
Omaha,NE 68183
Re: Kum & Go, L.C. DBA Kum & Go #351
Dear Clerk:
Enclosed is a copy of a manager application for Becky Borosko in connection with Kum&Go
#351, located at 720 N. 108th Ave., Omaha,NE 68154, liquor license #D-42739.
Please present this application for manager to your City/Village Council or County
Commissioners and send us the results of their action.
Sincerely,
NEBRASKA LIQUOR CONTROL COMMISSION
c4 ?
Licensing Divi 'en
encl.
cc: file
Rhonda R. Flower Bob Logsdon R.L. (Dick)Coyne
Commissioner Chairman Commissioner
An Equal Opportunity/Affirmative Action Employer
I
Printed with soy ink on recycled paper
, AUG-18-2006 FRI 10: 19 AM KUM&GO, L, G, FAX NO, 5152231606 P. 01/02
APPLICATION FOR LIQUOR LICENSE
CORPORATION MANAGER- FORM 3b
*MUST BE A NEBRASKA RESIDENT*
301 CENTENNIAL MALL SOUTH 1. ,3 2 r. 2300'
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 • r.
FAX:(402)471-2814
Website:http://www.lcc.ne.gov! ! --^ •
LIQUOR LICENSE INFORMATION
NAME OF LICENSED CORPORATION KUM&GO L.C.
CLASS&LICENSE NUMBER
TRADE NAME 1/?2 q/ 67,0 C/
STREET ADDRESS ZZD /L 7-e•74c7 /4P:e" CITY �yd-/�A!--i—, //6i/
414 e r• • • •
SIGNATURE OF CORPORATION PRESIDENT/CEO
APPLICANT INFORMATION (MUST BE 21 OR OVER AND NEBRASKA RESIDENT)
NAME BECKY BOROSKO
ADDRESS 6017 N 108TH AVE CIR
CITY OMAHA STATE NE
ZIP CODE 68164
HOME PHONE NUMBER(402)616-5540 BUSINESS PHONE NUMBER(402)616-5540
SEX Q MALE U FEMALE SOCIAL SECURITY NUMBER
DATE OF BIRTH 1 _ PLACE OF BIRTH OMAHA, NEBRASKA
DRIVERS LICENSE NUMBER&STATE NE
SPOUSES INFORMATION (IF NOT MARRIED INDICATE)
SPOUSE NAME NOT APPLICABLE
SOCIAL SECURITY NUMBER DATE OF BIRTH
DRIVERS LICENSE NUMBER&STATE
FORM 35-4013
REV.4/05
1
f
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1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY.
Has anyone who is a party to this application,or their spouse,EVER been convicted of or plead guilty to any charge. Charge means any
charge alleging a felony,misdemeanor,violation of a federal or state law;a violation of a local law,ordinance or resolution. List the nature
of the charge,where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this
application. If more than one party,please list charges by each individual's name.
DYES DNO
If yes, please explain below or attach a separate page.
2. Have you or your spouse ever made application for any liquor license or manager for any liquor license? IF YES,for what premise give
license number and date.
OYES ONO
3. Have you or your spouse ever made a compromise settlement for violation of such laws?
OYES I7 NO
4. Do you,as a manager,have all the qualifications required by any person entitled to hold a Nebraska Liquor License?
Nebraska Liquor Control Act(§53-131.01)
CJ YES ONO
5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application?
A YES ONO
RESIDENCES FOR THE PAST 10 YEARS,APPLICANT AND SPOUSE MUST COMPLETE
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE
FROM TO YEAR
FROM TO
OMAHA, NEBRASKA 2004 2006
LAVISTA, NEBRASKA 1979 2004
EMPLOYERS- LIST LAST TWO EMPLOYERS
MONTH/YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO
KUM & GO LC DAN GROSS (515) 226-0128
MILLARD PUBLIC SCHOOLS RENEE VERMASS
FORM 35-4013
REV.4/05
✓'
I
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I" ,j 2 �' 200o
PERSONAL OATH AND CONSENT OF INVESTIGATION
MUST BE SIGNED BY APPLICANT & SPOUSE 4 '.!7.-
-.
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,an 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.
Aledee
W/2P—
S' nature of Applicant Signature of Spouse
Subscribe "tlly presence a swot befor -me this /,.f4� Subscribed in my presence and sworn to before me this
day of ✓ day of .
GENERAL NOTARY-State of Nebraska
: GINGER GUILFOYLE
7 7 * - -. 7 °.:" My Comm,Exp,June 10,2001
No ry Signat & eal Notary Signature&Seal
•
SillitiWilillitilielik
FORM 35-4C13
REV.4/05
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