RES 2004-0920 - Appoint Vrian W Brunow manager of 20's Night Club STATE OF NEBRASKA RECEIVED
Mike Johanns 0 N 9 AM 8; �NEBRASKA LIQUOR CONTROL COMMISSION
Governor Hobert B.Rupe
CITY CLERK Executive Director
301 Centennial Mall South
OMAHA, NEBRASKA P.O.Box 95046
• Lincoln,Nebraska 68509-5046
Phone(402)471-2571
Fax(402)471-2814
TRS USER 800 833-7252(TTY)
June 28, 2004
•
City Clerk RE: Manager Application for License#C11738
Omaha/Douglas Civic Center Applicant - Brian W Brunow
1819 Farnam, LC-1 Mickey's Enterprises Inc
Omaha NE 68183 "20's Night Club"
7301 Farnam
Omaha NE 68114/Douglas County
Dear Clerk,
Enclosed is a copy of a manager application for Brian W Brunow. It is filed in connection with the Class C
Liquor License of Mickey's Enterprises Inc.
Please present this application to your City Council and send us the results of that action.
Sincerely,
NEB SKA LIQUOR CONTROL COMMISSION
ALSOr\-
Jill Nelson
Licensing Division
enclosure
cc: enforcement
follow-up file
Rhonda Flower Bob Logsdon R.L.(Dick)Coyne
Commissioner Chairman Commissioner
An Equal Opportunity/Affirmative Action Employer
V-4/ '
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Application for Corporate . t�..}} •
*Must Be A Nebraska Resident* is
Please submit in Triplicate P ' CirED
Return to: Nebraska Liquor Control Commission,PO Box 95046
iei
301 Centennial Mall So.,Lincoln NE 68509 JO
" 2
Phone: (402)471-2571 Fax:(402)471-2814 Web address: http://www.nol.org/home/NLCC/ livz 2004
LIQUOR LICENSE INFORMATION E0�l'ROgSKq�4
NAME OF LICENSED CORPORATION CLASS&LICENSE NUMB e
ni,(web'c £n of-pc;s es Ic , glass C -A��o�, ��//
c,4c ,c d/ oifscl12
TRADE NAME.OF LICENSED PREMISE
ao's I ;yi � cit16REGEivED
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
A:K:
r)30, RA rn4vn OPACI1 yr .�oC`c� �4S 2L1100t
On behalf of the corporation.I designate this individual as corporate manager. NE�R
SIO
OR
Signature of Corpo to President/CE,Op• )/" ONTROL COMMISSION
APPLICANT INFO, TION (MUST BE 21 OR OVER)
NAME.(LAST,FIRST.MIDDLE,MAIDEN) SEX SOCIAL SECURITY NUMBER DATE OF BIRTH PLACE OF BIRTH
W II E C� wc•/eil
HOME STREET ADDRESS J� � CITY COUNTY STATE 7IP('ODE /
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&STATE
9Q2,.) 6i6 — a,1'1 (Vol) 37/ -3/6 /
SPOUSE'S INFORMATION(IF NOT MARRIED INDICATE NONE)
FULL NAME.(LAST.FIRST,MIDDLE,MAIDEN) SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER
&STATE
a4hCrO? 'g,cnt0t,J, `64( iI.spAd gacro-.F/
, • ) w 1 a,
DATE OF BIRTH: PLACE OF BIRTH: G µ ^ e, ce4 J_r ��
I. 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 criminal charge?Criminal
charge means any charge alleging a felony or misdemeanor violation of a federal or state law;or 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 pendin at the time of this application. If more than one party,please list charges by each individual's name.
Li YES ANO
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.
YES 2S.: N()
1r. .
n\rg I
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3. Have you or your spouse ever made a compromise settlement for violation of such laws?
YES X NO
4. Do yott;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)
YES NO
5. Have you:filed fingerprint cards and PROPER FEES(if check,made out to the NE State Patrol),with this application?
XYES: Ll NO
• t.,.
LIST PRINCIPAL RESIDENCE FOR PAST 10 YEARS,APPLICANT AND SPOUSE MUST COMPLETE
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR•
FROM/ //,, FROM r, TO /� FROMQ TO
��h cal n /��6+ {{SIIC.. �T C�uGnC. /C1 �4 / d(t/a /
i.17-4; c� G J//.r c 7A. -- S 98'1 K tE'Cott mow 99 a Y � -mow �w�• 00Mw�z,. 57.41i,/ rot.L 9 ") 5 O icier Calo r-A�L q`I' 9 i
<_oc,hc:[ �0w� 9� Qrj� /� 3 9`I• 0--,4Ar`'hstile: A) 9L CI PS Ad,, CO -Z,L✓G.. 9
EMPLOYERS—LIST LAST TWO EMPLOYERS
YFAR NAME OF EMPLOYER NAME OE SUPERVISOR I ELEPIIONE NUMBER
FROM To l 1 )
%9 —' �G✓ e►tns 5�oLiy ,'i: 6e✓1✓ty 11/�or;uaI l
:h ( 1)391-3/,<;/
q 99 6ri7-e,u ',, oe ! t-oltr-GS coa . / /_, 3a,s...5 it,»
• J
PERSONAL OATH AND CONSENT OF INVESTIGATION—MUST BE SIGNED BY APPLICANT&SPOUSE
STATE OF NEBRASKA ) 1
) SS
COUNTY OF )
The above I dividnal(s),being first duly sworn upon oath,deposes and states that the undersigned is the applicant and/or spouse of applicant who makes the abuse and foregoing
application.that said application has been read and that the contents thereof and all statements contained therein arc true.if any false statement is made in an) part of this
application.the applicantls)shall be deemed guilty of perjury and subject to penalties provided by law.ISce:953-131.01)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.tas 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 mas 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 may be attached however,fingerprint cards are still required to be filed.
The nude'signed understand and acknowledge that any license issued,based on the information submitted in this application,is subject to cancellation it'the info'matins
contained herein is incomplete and inaccurate.
r e—
(--- . _____
gnature of Applicant Ignature of Spouse lif applicable)
Subscribed in •presence and sworn to before me this /`Y" Suhscrihi'd in presence and swans to before me this d"._.
day of �--✓ t•�#T day of_ o O V_•
Rieseep,Y4 d-,z-y-7
- oled-Ci--Ef-e&L‘Le,s.,
Notary Signature&Seal / Notary Signature&Seal
UK 11 a5.al�lf
6&NEQII NOTAttT-Siyb o1 Nebraska t :, (
G<ESCYNIHIAANNo ROGERS I GENERAL NOTARY-State of Nebraska t•-11
,1 .
%ycanon.E .Feb.22,YD07 ROBERT D.ANDERSON
—' -a a MY Comm.Exp.Nov 15,2006
. , , NEBRASKA LIQUOR CONTROL COMMISSION
AFFIDAVIT OF NON PARTICIPATION
- 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
ity
tend bar,make sales,serve patrons,stock shelves,write chec h,. i invoices,represent the t 4..;' in
any way participate in the day to day operations in any capa III. Ci :li , 'ved of filing VED ,
fingerprint cards,however,has disclosed any violation(s)on the appjjMioo.8 200` ��e ti 1 2004
CON NE
CoNrpo SKa t� i
�SKA LIQUOR CO QUO
Signa re pouse CONTROL COMMISSION 0
Miss1 N
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SUBSCRIBED in my presence and sworn to before me this �� —day of ,A.D.,e100.Y
GENERAL NOTARY-State of Nebraska ,�
Ali ROBERT D.ANDERSON
IV
My Comm.Exp.Nov.15,2006 �L-�-A¢.�G
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.
-j.,,,
( SZei of �censee/Applicant Print Name of Licensee/Applicant
SUBSCRIBED in my presence and sworn to before me this /' day of G i/ ,A.D.,4,2,8
Signature of Notary Public
AL NOTARY Slate cf Ne a�
FaESCYNiHIAANN ROGERSFORM 35-4178
M/C . eb. 2007Lr r.:�_ REV 2/01
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