RES 2002-2744 - Appoint Courtney A Haynes manager of Connections STATE OF NEBRASKA RECEIVED
saE era- NEBRASKA LIQUOR CONTROL COMMISSION
02 DEC -5 n iit 8: 49 Forrest D.Chapman
i,i Executive Director
F� � '+1:�; 301 Centennial Mall South,5th Floor
W'� "'r "'m'; P.O.Box 95046
CITY C L P K Lincoln,Nebraska 68509-5046
s ie;Ay O�'�!'#H�., t'C t i� '�,'i �` Phone(402)471-2571
o
�' �" Fax(402)471-2814
TRS USER 800 833-7352(TTY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor
November 27, 2002
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 KelVal Inc DBA
Connections located at 1901 Leavenworth Ave, Omaha, NE 68102 (Douglas County) which holds
a Class I License #44097 the applicant's name is Courtney A. Haynes.
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,
Michelle Porter
Licensing Division •
Enclosure
Rhonda R.Flower Bob Logsdon R.L. (Dick)Coyne
- Commissioner Chairman Commissioner
An Equal Opportunity/Affirmatiue Action Employer
Printed with soy ink on recycled paper
•
• Application for Corporate Manager
*Must Be A Nebraska Resident* RECEIVED
Please submit in Triplicate
Return to: Nebraska Liquor Control Commission,PO Box 95046 NOV 2 7 2002
301 Centennial Mall So.,Lincoln NE 68509
Phone: (402)
471-2571 Fax: (402)471-2814 Web address: http://www.nol.org/home/NLCC/
:::.:::........ ....... ..............::... ........:......... ....... ............ ................- .. ........ P'://www.no..._g/home/NLCC/ n o � �[ll1(�Fj•
NAME OF LICENSED CORPORATION CLASS&LICENSE NUMBER
4,40 9/
TRADE NAME OF LICENSED PREMISE
Co J C.C. Ca 1,3 5
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
°I LePSU -N wog Au OMAviA DDuc1LA-5 ' to5102.
On behalf of the corporation,I designate this individual as corporate
Signature of Corporate President/CEO:
........................................ .......... .: _
NAME(LAST,FIRST,MIDDLE,MAIDEN) SEX SOCIAL SECURITY NUMBER DATE OF BIRTH PLACE OF BIRTH
I�AylJGS� CouRTrlBy At- X 15 ' 1 i9 75 Co - ,ncoRo N 1-1
HOME STREET ADDRESS CITY COUNTY STATE ZIP CODE
8 4 51-eEe'r vMRNA
DouGiAs >v E 68 lo(p
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&STATE
(t(n ) 6111-942 i- (G28d9 6a7 IVL
FULL NAME(LAST,FIRST,MIDDLE,MAIDEN) SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER
SINGLE &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
charges pending at the time of this application. If more than one party,please list charges by each individual's name. •
tlYes ❑No
V2ose See (3.40.ahmer- ( •
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 ONO
FORM 35-4013
REV 2/01
primed co recycled Wet PAGE 1
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)
lYES ONO
5. Have you filed fingerprint cards and PROPER FEES (if check,make out to the NE State Patrol),with this application?
(AYES ❑NO
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
"PI e.0.S + See- a{Fa C k Mend moo( FROM TO FROM TO
.EngERNERMENNEREERWROMstaiioyms.i; timuukstfrivoi.smn-LoyeRsom=imiimmiimomi=ii.i::::Nrimaimm
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
.FROM TO
•
o?DOQ, ?ceSer,1- Cow^� �ion5 Kelly Thbrvw.S ziod 733r3o33
d0oL' ?re�enk ?roCare3 I'1.Qtidy �l;\y1e3 yoa-330-78q
::::g> > PRSDN (}ATRAT CO ENT*TMEE..STI * IIN.:-.M1 T.:BE.:.S:. �D.BY:.. .. . I. : .. . ..S ..;:.::.;::.:.;;:.:.:.;:..
INS........:..:: LIST.�:.SP�3II��::::._::::::...:..
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.§53-13 1.01)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 ifthe information contained herein
is incomplete and inaccurate.
/4\i
1
Signature of Applicant Signature of Spouse(if applicable)
Subscribed in my presence and sworn to before me this pC/ Subscribed in my presence and sworn to before me this
day of Ai n!J oleo • day of
;. -lLLQ/t1�G Sto
�
Notary Signature Seal Notary Signature&Seal
GENERAL NOTARY-State of Nebraska
in. CATHERINE ANN AGOSTA
My Comm.Exp.NOV.8,2004
FORM 35-4013
REV.2/01
• PAGE 2
, ECE VED
Attachment # 1: Application for Corporate Manager N 0 V 2 7 2002
Applicant: Courtney Alexis Haynes NEBRASKA LIQUOR
CONTROL COMMISSION
Question 1: Between 1991 and 1999,I received speeding tickets in the state of
Missouri. I do not know how many nor the specific year I received them. I contacted the
State of Missouri Department of Motor Vehicles and was told my driving record had
been purged. All they could tell me was that my record had been purged in 2002,that I
had no revocations or suspensions, and that I had voluntarily surrendered my Missouri
Driver's License(when I obtained a Nebraska Driver's License).
In February, 2001, I was involved in a motor vehicle accident in Nebraska. I was cited for
driving too fast for the weather conditions. I was able to take a defensive driving course
in lieu of the ticket, which I completed February 27, 2001.
I have not been convicted of any other violations.
•
RECEIVED
NOV 2 7 2002
Attachment# 2: Application for Corporate Manager NEBRASKA LIQUOR
CONTROL COMMISSION
Applicant: Courtney Alexis Haynes
Residences for the Past 10 Years:
Omaha,NE 1998—Present
Meredith,NH 1998
Galway, Ireland 1997-1998
Meredith,NH 1997
Bennington, VT 1997
Cambridge, MA 1997
Atlanta, GA 1996
Bennington,VT 1996
New York City,NY 1996
Bennington, VT 1995
Princeton,NJ 1995
Atlanta, GA 1994-1995
Rolla, MO 1994
Bennington, VT 1993 - 1994
Rolla, MO 1992— 1993
�MAHA, NFB
City of Omaha fAlebras&a 0 NI 's�
1819 Farnam—Suite LC 1 zi -.tV �o
Omaha, Nebraska 68183-0112 0® �
�: i ce;_;;
Buster Brown (402) 444-5550
A (1."City Clerk FAX (402) 444-5263 oR'TD FEBR‘3r4�
December 2, 2002
KelVal, Inc. Application to appoint Courtney A. Haynes
Dba"Connections" manager of your present Class "I" Liquor
1901 Leavenworth Avenue License
Omaha,NE 68102
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application to appoint a manager to the liquor license has been set for December 17,
2002. - The City Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-
4), Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha, Nebraska. City Council
Liquor Rule No. 6 states, "Each applicant for any type of license shall be personally
present in the Council Chambers, in order that the Council may make inquiries, on the
date of public hearing of the application for said license". Failure to be present at this
Council Meeting is grounds to recommend denial of your application to the Nebraska
Liquor Control Commission.
City Council Rule No. 14, requests each applicant to submit a signed statement
representing that a sign indicating the birth date for buyers of alcohol will be prominently
displayed on the licensed premises and that approved training in the proper procedures
for checking buyers' identification will be provided to employees. Attached is the
statement to be signed and returned (hand deliver, mail or fax) to the City Clerk's Office
before your public hearing. FOR YOUR FILE, ATTACHED SENT TO MANGER.
Since ly yours,
Buster Brown
City Clerk
BJB:clj
OMAHA, N
City of Omafia, We6ras&a :
arifirV-%eril
1819 Farnam—Suite LC 1 z
Omaha, Nebraska 68183-0112 0�.�
Buster Brown (402) 444-5550 .o N.
City Clerk FAX (402) 444-5263 O�4TFp FEBR°*4�
December 2, 2002
Courtney A. Haynes Application to be appointed manager of the
5819 Frederick Street Class "I" Liquor License for Kelval, Inc.,
Omaha, NE 68106 dba"Connections", 1901 Leavenworth Ave.
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application to be appointed manager of the liquor license has been set for December 17,
2002. The City Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-
4), Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha, Nebraska. City Council
Liquor Rule No. 6 states, "Each applicant for any type of license shall be personally
present in the Council Chambers, in order that the Council may make inquiries, on the
date of public hearing of the application for said license". Failure to be present at this
Council Meeting is grounds to recommend denial of your application to the Nebraska
Liquor Control Commission.
City Council Rule No. 14, requests each applicant to submit a signed statement
representing that a sign indicating the birth date for buyers of alcohol will be prominently
displayed on the licensed premises and that approved training in the proper procedures
for checking buyers' identification will be provided to employees. Attached is the
statement to be signed and returned (hand deliver, mail or fax) to the City Clerk's
Office before your public hearing.
Sincerely yours,
Buster Brown
City Clerk
BJB:clj
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