RES 2006-1137 - Appoint Becky Borosko manager of Kum & Go #372 STATE OF NEBRASKA
t{1 7� ty , � ,
Dave Heineman R j.-L- C-1 7
� •��a F NEBRASKA LIQUOR CONTROL COMMISSION
i , , Governor Hobert B. Rupe
+ fi''w?RCH��• _ 06 Sc_r 12 8, 4 Executive Director
9
301 Centennial Mall South,5th Floor
CITY +� !?ll tt P.O.Box 95046
O M A H 1-‘, R E B R l S 1. a Lincoln,Nebraska 68509-5046
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#372
Dear Clerk: -
Enclosed is a copy of a manager application for Becky Borosko in connection with Kum& Go.
#372, located at 7152 Pacific Street, Omaha,NE 68106, liquor license#D-47280.
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
Ka 'e L in
Licensing • is n
encl.
cc: file
•
Rhonda R. Flower Bob Logsdon R.L. (Dick) Coyne
Commissioner Chairman Commissioner
• An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
AUG713-2006 FRI 10: 19 AM KUM&GO, L, C. FAX NO. 5152231606 P, 01/02
APPLICATION FOR LIQUOR LICENSE
CORPORATION MANAGER-FORM 3b
*MUST BE A NEBRASKA RESIDENT*
301 CENTENNIAL MALL SOUTH
PO BOX 95046 rP
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 �(
FAX:(402)471-2814
W ebs ite:http://www.lcc.ne eov/
LIQUOR LICENSE INFORMATION
NAME OF LICENSED CORPORATION KUM&GO L.C.
CLASS&LICENSE NUMBER 7'7-0W
TRADE NAME / , /2 QL -"
STREET ADDRESS_ t7/�.-? ,4e'/A e Zjif CITY 11���� /6
140
(71):
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 0 MALE A FEMALE SOCIAL SECURITY NUMBER
DATE OF BIRTH 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.4r'05
• '
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 ONO
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.
DYES �✓ NO
3. Have you or your spouse ever made a compromise settlement for violation of such laws?
DYES NO
4. Do you,as a manager,have all the qualifications required
q by any person entitled to hold a Nebraska Liquor License?
Nebraska Liquor Control Act(§53-131.01)
I YES ONO
5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application?
YES DNO
RESIDENCES FOR THE PAST 10 YEARS,APPLICANT AND SPOUSE MUST COMPLETE
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
FROM TO 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
,-
. _ (✓ 1. _„
PERSONAL OATH AND CONSENT OF INVESTIGATION _ _
MUST BE SIGNED BY APPLICANT & SPOUSE
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 againct
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.
#141
S' nature of Applicant Signature of Spouse
Subscribe 'r ray presence a d sworrt bef me this /.. . Subscribed in my presence and sworn to before me this
day of �'' .?ei, �T day of
•
', GENERAL fJOTARY-State of Nebraska,200r
GINGER u1LFO11'�E
• > 7
' My Comm.Exp,June 10
No ry Signa & eal / Notary Signature&Seal
•
SiseptitiONIONINkili
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FORM 35-4013
REV.4/05
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