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RES 2006-0358 - Appoint Peter Axelson manager of Romano's Macaroni Grill .1" y STATE OF NEBRASKA t.d,';w?:; 6g_ ,,,, F, Dave Heineman ,47•4,,% Governor NEBRASKA LIQUOR CONTROL COMMISSION -'"_ 4 2 Hobert B. Rupe M9R In-j86 �' Executive Director --,. t- - 301 Centennial Mall South,5th Floor EsI i i l P.O.Box 95046 O M A H A, NEBRASKA 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/ March 23, 2006 Omaha City Clerk 1819 Farnam St LC1 Omaha NE 68183 Re: Brinker Restaurant Corp Dear Clerk: • Enclosed is.a copy of a manager application for Peter Axelson in connection with Romano's Macaroni Grill, located at 701 N 102nd Street, Omaha, liquor license#C-46875. 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 (Ttbymu Holly Erickson Licensing Division 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 APPLICATION FOR LIQUOR LICENSE CORPORATION MANAGER-FORM 3b _ *MUST BE A NEBRASKA RESIDENT* FE B 2 7 2006 301 CENTENNIAL PO BOX 95046 MALL SOUTH NEBRASKA LIQUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE:(402)471-2571 FAX:(402)471-2814 Website:httn//www.lcc.ne.gov/ NAME OF LICENSED CORPORATION (eXnMC.(i -USAC MAJW CD • CLASS&LICENSE NUMBER C— `b TRADE NAME i2a.1 AN Os Il o 1 Sai LL- STREET ADDRESS /4)1 t '- i OZ"d S'1-t'ct f CITY 0traha., j Cfrek r§inWa iDit ©, QN ParthWjttQ,O, { ' ? • �' �Y A : tL1V r n\r7F RM Ir C t sT B µ, 1,0 QMP„ ABM MEND NAME ?e- tc Ax. n ADDRESS ,A0 b5-0 I �l 3 - CITY D 4 .-- STATE ly ZIP CODE (V 1 I HOME PHONE NUMBER C�oZ)_135—Q5w Z BUSINESS PHONE NUMBERMOZJ 15S - loco SEX%MALE D FEMALE SOCIAL SECURITY NUMBER C. _ DATE OF BIRTH •, - .. . PLACE OF BIRTH Cant k*, C h. DRIVERS LICENSE NUMBER&STATE_ IMJA SPO :SE ORMA �1:®i\ 'l 1 O'A� .u< i r ® 1)rrk, k'WOW r a f. : t �s ..5 ` ; SPOUSE NAME 1 6 Ay..aso SOCIAL SECURITY NUMBER _ : _ DATE OF BIRTH DRIVERS LICENSE NUMBER&STATE _ - 1Welk FORM 35-4013 REV.4/05 03/13/2008 MON 17:03 FAX 402 471 2814 NE LIQUOR CONTROL 2 002/002 • RECELVED t:I, R 17 -cir03 APPLICATION FOR LIQUOR LICENSE NEBRASKA U*`'., ! 'ox ,, xra tf ti CORPORATION MANAGER-FORM 3b CONTROL COM S �� �- *MUST BE A NEBRASKA RESIDENT r-� u Ls.;;J a MALL SOUTH LIQUOR PO BOX UX 95046 95046 L1N(:U:(4 N6 71-25 S1 CONTROL COMMISSi 1 Y11UNli:(402)47I-2571 • i�tl7u' FAX:(402)471-2R14 Wchhirct hiln://WWW Ic'i ernvl 1 n Y * tp t 1 r#A 1, ' �t }'N� !r "{'� � '11 'R' Ik •1 ff �}' t!°� � 4�• 6 ,,pp�� f (( f i;��{{�ii Y" V71i;'d .'{Fi`,t,� 4 1" , ,t 1 .. 4,(II{t !�' .YI!r ! y' +� �'�tcZ.:>.iY.� �i�`.QF �.��I tr+r SST NAME OF I.TCENSi I)CORPORATION Vat*CLra C(9 n CLASS&LICENSE NUMBER ' Lh0 DIS TRADE NAME ¶?ou � � 1� I 121�. L_-- STREET ADDRESS �"®‘ " 1 o�n� 9tree¢ CITY Omaha_ u ugp n. fpron .1(`7Yit!6`''S'.qU�ga�1�A. j•.1:�7 m�i�'l:Li* n,��1 a,,++r lfn nl IA,$R d�. n,ppl,,�.{ yy�ly ( 1 . l:w0 �:00R3 WiiO uO I ry u F,P40 NU W a i+U j k:,`'' i•hi u i ! A ivOitt p Y + ME EN �w2 g !WU NAME W� (x- Au n AD0ttSs t &(o l'1 Q( Lt+ ' - . CITY �'"� STATE + 7 rIP CODE .1d 3 HOME PHONE NUMBER(�yOZ) F BUSINESS PHONE NUMBER(!4O# 1sc I WO SEX%MALE®FEMALE SOCIAL SECURITY NUM131LR _ , -- - DATE OF BIRTH , -. PLACE OF J31R'I'I I Can 0-.t rlC , DRIVERS LICENSE NUMBER&STATU I _ ME n fI MM EN Ma l EWE I A EhA Y EINI' I 1 E � I SPOUSE NAME 1— Ayllson t SOCIAL SECURITY NI JMHER DATE OF BIRTH . DRIVERS LICENSE NUMBER&STATE - : - «k FORM 35-4013 AM LAMS d/0S 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. OYES 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 INO 3. Have you or your spouse ever made a compromise settlement for violation of such laws? DYES ONO 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) FlYES ONO 5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application? YES ONO RESIDENCES FOR THE PAST I YEARS,APPLICANT AND SPOUSE MUST COMPLETE , APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR FROM TO FROM TO ?itfg a- PC 7061.- ZOOS ?Gala- 1 1 ' 2602 uos Itt ral kce. , t ?cot 24- AhuAI*11- - 1tz 2m zeo ! c edomo- CA 70e0 ?wt. Pcitikmo►., C.4 -moo zeD 5aaretatcmo Cdt tqfts two Aftararnu CA 1177- Zero EMPLOYERS LIST LAST.TWO EMPLOYERS; , MONTH/YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO ?.00 Gvr WI* 1?om�,rrt;s f lct ivoa1 Etr,1l Wlicr )1-001614 33 r ttti-336 la t9 2003 O1%vL. C4ic rdcAi c)OIi t W's1c fo)- FORM 35-4013 REV.4/05 D FEB 2 7 2006 PERSONAL OATH AND CONSENT OF INVESTIGATION MUST BE SIGNED BY APPLICANT&SPOUSE CONTROL COMMISSION 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. 67 C. ...... ---1(2--) aA4e,&L.- _ Signature of Applicant '41ignature of Spouse Subscribed in my presence and sworn to before me this � i Subscribvtin my presence and sworn to before me this day of T-OCf l -0Lr'i , ZOO to . day of -60 if i-i_C&f 1 1 ZOoh O'') ):- 0_9-JO),-/Y0 '&0) .- WW317/(\-) Notary Signature&Seal Nntnry Cign.41F..raX.S"-' ' GENERAL NOTARY-State of Nebraska iI LORI OLSEN GENERAL NOTARY-State of Nebraska • My Comm.Exp.March 21,2009 LORI OLSEN �:_:...-". My Comm.Exp.March 21,2009 FORM 35-4013 REV.4/05 . RE '. EIVCRI. ' FEB 2 7 2006 NEBRASKA LIQUOR CONTROL COMMISSION AFFIDAVIT OF NON PARTICIPATION NEBRASKA LIQUOR CONTROL COMMISSION The undersigned individual acknowledges that he/she will have no interest,directly or indirectly, in the operation or profit of the business, as prescribed in Section§53-125(13) of the Liquor Control Act. Such individual shall not tend bar,make sales,serve patrons, stock shelves, write checks, sign invoices,represent themselves as owner or in any way participate in the day to day operations in any capacity. Undersigned will also be waived of filing fingerprint cards,however, has disclosed any violation(s)on Pi<te Sig ature of Spouse th SUBSCRIBED in my presence and sworn to before me this a1 day of T--e-b r uo c-1 , ZOO 6 . GENERAL NOTARY-State of Nebraska ( ( - J LORI OLSEN `s My Comm.Exp.March 21,2009 Signature of Notary Public The licensee/applicant understands that he/she is responsible for compliance with the conditions set out above,and that if such terms are violated,the Commission may cancel or revoke the license. C\ ?. .---0_,..) 1 • Aekoi gnature of licensee/ap icant Print name of licensee/applicant SUBSCRIBED in my presence and sworn to before me this ci, i day of ceb f k,c,,sr 1 , ZrJo to . GENERAL NOTARY-State of Nebraska a ��� LORI OLSEN M Comm. March 21,2009 Signature of Notary Public FORM 35-4178 REV 2/01 > 8 K ƒ 7 1 @ A § § ? § @ n § 2 9 R o ; - \ ril R R & j C of q oa ` / c) § 9 . G § / k 'N1/4, \ § ° \ lb � 0 q N 07 go 4 n ¢ « k cr ECl) pD q � \ � n ¢ ° Ct x t g 1