RES 2004-0084 - Appoint Ronald Bradstreet manager of Hometown Garden Café & Bakery STATE OF NEBRASKA
RECEIVED
,SgE`S NEBRASKA LIQUOR CONTROL COMMISSION
v o� 0JAN
_7 !.b Forrest D. Chapman
r 1`' 20 AM 8: �b
Zy Executive Director
F' ,�, 301 Centennial Mall South,5th Floor
m, t �' CITY CLERK P.O.Box 95046
�' `j � ;'.°"% OMAHp NEBRASKA Lincoln,Nebraska 68509 5046
t~�s €�3 Phone(402)471-2571
���Z`9Rctr i"'�� - Fax(402)471-2814
TRS USER 800 833-7352(TTY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor
January 5, 2004
City Clerk
Omaha/Douglas Civic Center
1819 Farnam LC-1
Omaha NE 68183
RE: Manager Application Submittal
Dear Sir/Madam:
The enclosed Application for Manager is being submitted by Boss Management LLC
DBA Hometown Garden Café Grill &Bakery located at 11039 Elm Street, Omaha, NE 68144
(Douglas County) which holds a Class C license #60721 the applicant's name is Ronald
Bradstreet.
Please present this application to your City/County Council and return to us the results of
the action taken. If you have any questions or comments,please give me a call.
Sincerely,
41WUW5IL
Miche orter
Licensing Division ..� .....,
Enclosure
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 Corporate Mana. _ .
*Must Be A Nebraska Resident* ;~� r
Please submit in Triplicate ,
-. Return to:. Nebraska Liquor Control Commission,PO Box 950461"' _/ pre 3 1 20Q
301 Centennial Mall So.,Lincoln NE 68509 `� �
Phone: (402)471-2571 Fax: (402)471-2814 Web address: http://www.nol.org/home/NLC CYL.—.01
NAME OF LICENSED CORPORATION CLASS&LICENSE NUMBER
(DD-1D1 elckss C, (IL- '
TRADE NAME OF LICENSED PREMISE
kfy102-6,3 (--r/s-O, Gio C-)c;U, ---Eaka, rit- Ci\-e
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
1 DC\ -6 rn ems+ . \� Lrno l c\' 4 �DoucjC&S 't --' Log 144 tit-
On behalf of the corporation,I designate this individual as corporate manager.
Signature of Corporate President/CEO: ------ -- t-L"
........................................................................................ ....... ................................... ... .....
NAME(LAST,FIRST,MIDDLE,MAIDEN) SEX SOCIAL SECURITY NUMBER DATE OF BIRTH PLACE OF BIRTH
F M1 '
HOME STREET ADDRESS 1 CITY COUNTY STATE ZIP CODE -a_-r l
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&STATE
&`'1!- 8Loci ( La-) 593- ca5a e
. : I IND A i::is4::::.:: :::::::�S: {is -$::�u ::!:::i:�:::::i::i:::
i ::}}iiii}:::::ii:::::iiiii:iii is i:: ::::i:::i:ii::i::i
ii: :: iiiii'ii:iii :: ::!C:i iiii :i ',�1-�y}Y� j/�,,
::iii:>::i'iiiiii:::i;ii iiiiiiiiiiiiii:i:::::':::::::ti':'}::::i:: idJ[�:�.�5''i} .................�!!............. ..............................n.................... . ....
•
FULL NAME(LAST,FIRST,MIDDLE,MAIDEN) .l SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER
iA
.ye_T i\I tl .. r &STATE
DATE OF BIRTH: PLACE OF BIRTH
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 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
c�h�arges pending at the time of this application. If more than one party,please list charges by each individual's name.
O'Yes L)No 1c1 (Da -1);u,i'.. --Dculc,s elx.,4 1L1E 1,1, (i.c,s1(s44 c le w
-Flb VA--1- bt.., Li,o1ckt;;-U. 036,:F..) - Nu,�IGi_S Oc,,,;.)1 - 1\\t-1 Gk,f-, Pler'-
1 li%;1 z_— i i, ,3 Yi ' i >cl ( nicf-.1 /-- ,90 s(4.. i Y. .;)�tit. �
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 numberb and date.
DYES ^NO
a
FORM 35-4013
REV 2/01
mbd on Pacer
1
p
•
•
3. Have you or your use ever made a compromise settlement for violation of such laws? ,r
AYES NO •
4. Do you, as a manager, have all the qualifications required by any person entitled to hold a Nebraska Liquor License?
Ne],,:waskaLiquor-Con4rol.Act(§5:3-131.01)
IidYES • ` :CNO :.,
5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application?
'YES ENO
............:..:.:....::::::::::::::::::::::.............................
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
, FROM TO FROM TO
lcict? Dc3 jJ
ivs i1`1 iGcn
Y _
...................................................................... :isiYii<iiv'::isv:{:S<�ii:{!:Jiiiii:4ii:::i'ititi^:iiiiii:iiii?i:':=:{•ii:!i{�}iii:4:^isviii}i::^iiiii:J:':{:i:4..:i4i:ii:•:-.-iiiiii::i:;+:::::.
NAME OF SUPERVISORTELEPHONE NUMBER
YEAR NAME OF EMPLOYER
FROM TO 1
ictqg 6\ cp r;sas-- (-otde Cc` .. r'h icr,.) LoC.k (41 C -17c3
1ctCp-............ 9.. 1.......1 Ir1 sl,ltw-e l rc,ccte.N G ......._....Cfa, C.
............
STATE OF NEBRASKA )
) SS
COUNTY OF )
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 and inaccurate.
Si of Applicant Signature of Spouse(if applicable)
Subscribed y pr i ce and swo before me this 7 � Subscribed in my presence and sworn to before me this
day
of � / 3 day�� GENERAL NOTARY-State of Nebraska
/ RI JEFF GASPER
/ My Comm.Exp.Sept 15,2005
i r / Notary Signature&Seal Notary Signature&Seal
FORM 35-4013
REV.J01
PAGE 2
— I
/ O f ? 7
§ @ q ƒ )
\ ' � \
• a
\ v m k P § �II
_ - • I 0 UP ' , § § q
2 / CM / 7
.1 % . I § \• \.
' ` r
( A 7 .
O . Q
» - N.,
0 2 0 Cr
w
\ 1` % o p
q q k \ m_
. " ' �_
o % o 3
1 ƒ 0 \
_ _ .