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RES 2023-0113 - Appoint Georgiana L Amoura manager of Residence Inn by Marriott E-MAI LED TO NLCC,, /`Zd Z 3 _--, .E`S T4 i:,,N =w; - ,2 , • STATE OF NEBRASKA 1 a :/ ;y Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION ;a""•'! '' „a p•x' Hobert B.Rupe a.�.�raA _ .w_�,,� Governor bi, a Executive Director ti' ,Z7 n 1a `p 301 Centennial Mall South • P.O.Box 95046 Lincoln,Nebraska,68509-5046 Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 TRS USER 800-833-7352(TTY) Web Address https://www.lcc.nebraska.gov Today's Date: December 30, 2022 From: Rebecca Roberts (rebecca.roberts@nebraska.gov) To: Omaha City Clerk I have attached a copy of a new corporate manager application submitted to the Nebraska Liquor Control Commission. Please complete the following information below to indicate your recommendation. • Licensee Name: Develotel Omaha LLC Trade Name (DBA): Residence Inn by Marriott t License Number: C-107237 Manager Name: Amoura, Georgiana L Due Date: February 13, 2023 APPROVED NO LOCAL RECOMMENDATION ❑ DENIED COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) Clerk's Name: Date: 7-- I - 2_6Z-3 Kim Lowe Bruce Bailey Harry Hoch Commissioner Chairman Commissioner An Equal Opportunity Employer +V 3 -0-ole a3-0I I � i (Aaik y gi/ ?-'-3 1 2022-11-08 15:11 A 1 >> 402 471 2814 P 1/9 1D1 a3 \ MANAGER APPLICATION vale vao : ‘ • INSERT-Form 3c RECEIVED . - • NEBRASKA LIQUOR CONTROL CM/SESSION ()V ��� •. 301 CENTENNIAL MALL SOUTH N • .s PO BOX 95046 LINCOLN,NE68509 5O46 NEBRASKA LIQUOR PHONE:(402)471.2571 CONTROL COMMISSION . FAX:(402)4714814 Websitc:www.icc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED • MA7GER MUST: Complete all sections of the application. Be sure it is signed by a member or corporate officer, corporate officer or member must be an individual on file with the Liquor Control Commission Fingerprints are required. See form 147 for further information,read form carefully to avoid delays • in processing,this form MUST be included with your application. . . Provide a copy of one of the following:US birth certificate,naturalization papers or current US •' passport(even if you have provided this before) •h Be a registered voter in the State of Nebraska,include a copy of voter card or print document tarn : • Secretary of State website with application trrraliel Spouse who w11 articipate in the business,spouse must: ; . vAil Complete the Spousal Affidavit of Non Participation Insert(must be notarized). Thenori= •; participating spouse completes the top half;the manager completes the bottom half: Be sure to , complete both halves of this form. • Need not answer question#1 of the application : Spouse who will participate in the business,the spouse must: �. • Sign the application ' C`' • Fingerprints are required. See form 147 for further information,read form carefully to avoid delays in processing,this form.MUST be included with your application. • Provide a copy of one of the following:birth certificate,naturalization papers or current US.passport . (even if you have provided this before) • Be a registered voter in the state of Nebraska,include a copy of voter card with application ' • Spousal Affidavit of Non Participation Insert not required • I TF . MT-1 d t • 2200013914 • Form 103. : ! ,-- Rev July 2018•+: Pap'ot6 2022-11-08 15:11 A 1 >> 402 471 2814 P 2/9 I MANAGER APPLICATION omco use RECEIVED IlVSERT-FORiV13c . N,EBRASKA LIQUOR CONTROL COMMISSION NO 2 " 2 2 Z , 301 CENTENNIAL MALL SOUTH PO BOX95045 NEBR , i'#�•,� , ?ij R LINCOLN,NE 68509.5046 PHONE:(402)471-2571 CONTROL COMMISSION FAX:(402)4712814 Webtite:www.Ice.oebraska.gov MUST BE: ✓ Include copy of US birth oitificatmaaluralizationlaper or current US passport ✓ Nebraska resident. Include cooy of voter rcidgrati011 card or print out document from Secrecy of State website ✓ Fingerprinted. Sea form 147 for further information,read form carefully to avoid delays in processing,this form MUST be included with your application ✓ 21 years of age or older '�"" ULiO`�e'o 7tL110,+_:��l�a�r'+.t,L��=��'.s`%:=.:.t.3;;c��.'r:„'.'�' ,'!�`1�!^;�'�r�.S�a. vw: fny_. .t: , • or.,.or....,.�L.._..✓ laftelOtelF666. 'Th. ' Name of Corporation1LLC: P VP.1 p-1- Dmaina �--�. ................— . ...... . v+6y tS1 tli t,,:r,1�'. t•?}y.,f `�h':�1'.�.�.•1...� .. . . .. . .,,_ i. �y w,a.;�:'t.Y'.:� r,,tt�'i f�Tj .l..t..i ,•V�::�5.',12:"?:C'lt „.. .. . 1in(;�It ,; 1� .�. '.'�.,o�_�?:�s':•!tprr.T�1:�ft��Y?;a1'':•'7,KUt.A.ir�_>l.J..p• Liquor License Number: ` y V t 18Ss Type ( , crow appuc&toe kava blar�c) Residence Inn eimilalWeet b� �Y1, ' Premise Trade 1�IamefDBA: ST L 04 : 18202 Cuming Premise StreetA.ddress• �8022 City:Omaha county,Douglas Zip code., • Premise Phone Number:402-289-9500 Premise Email addtess:georgianaa t@immhotels.com The individual whose name is listed as a corporate officer or ror managin officers or member rraemhers search your license form 3a or 3b or listed with the Commission. To see authorized information here, '0 wit t X ' Q _ATURE . l M �-AY CORPORATE OFFICER A1 A:Gri:G., z . -� "'" (Faxed signatures are acceptable) •t . Form 10: aav July 201E Pigo Z oft 2022-11-08 15:12 A 1 >> 402 471 2814 P 4/9 Wigtei-frifOrinaGi•iiiiiifibakiai lite,'61:41eir. AVEEEASE•t_'.RINT---refA2. :„,i_kl'el.,rfb:.:1.,,!...;.:,1. ,:.•': ,,-...',•,:'. ...i:',.., - • 1 Last Name:Am o ura ' FirstName:Georgiana L MI: ' 10433 Laurel Avenue ...,.. Home Address: ,,. city,Omaha county:Douglas zip Code:€‘802 LeaSt4 - .......-_____ .. I COI Home Phone Number:402-305-6826 Driver's License Number&State; Social Social Security Number. Date Of Birth:11.1111111111111 Place Of Birth: M aha . Email address:georgianaa@immhotels.com . •••• •. ,,..0,Lt6.0.Tt,:i0IFJ912,:Slack.760 41:SW;Oi ' 174....13:1c Q.):61;tgblfil•ID''Sat, iti 4174iAltiWit.V, ,;iS . Ito.e.. 'e<7)1",,,,,.,.f.. :;..' C..]YES 0 NO • '..; . . . ,;() se mid°cisii,:o•`;', .•-::V•'..?:=114:,•Jfegal.0.45,i-.1.'i:.,...:1.!;4: ::,f;:;,'P',M9!,',...,;-.7i;:Xt•'..k:....•: :::';.-...:r..';'*.•:.; '••. ..:'.. •'••":::,' ..,' '.: Spouses Last Name:Amoura rirst Name:Hassan S Social Security Number. .1:• , •, Driver's License Number&State: IIIIIIIIIIIMIll N E ,.... Place Of Birth:Am man 1 Jordan -Date Of Birth t. .---......---- .------..... 91; " W a S.:GET S labiANN.Aas,A4i,/.. ....;!,;:o.;06.4,i,,t•S,0 IS S ,., ,A,,L,p,,,.,...:, .,,... ,„".. a...,:,,.. h .,.. YEAR YEAR CITY&STATE YEAR . YEAR , CITY&STATE . . e FROIVI TO FROM TO Omaha, NE 2000 current .: .. . .., .,.,: ..; _. .„ :.: n=103 l'i,•,, Rtv Xuly 2018 Pngo 3 i:4:6 '. • %.".4 2022-11-08 15:12 A 1 >> 402 471 2814 P 3/9 ,.'rtx', ';1':•+'.i; :,�h.±S.N,ti�.l;''J:1'.;'aW..e',4V11 ',� .0 gi 0 .LtS ",'•;:;;'•:i�'• _ YEAR NAME OF EN,I LO' It NAME OF SUPERVISOR "IEL1�I'RONE FROM TO NUMBER 2021 current Intermountain Management Michael Ashley 479-269-5830 2020 2021 Lodging Dynamic Amber Harkin 801-919-3440 • ..> 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-.-; ' participation, •• • • Has anyone who is a party to this application,or their spouse,EVtR been convicted of or plead guilty to any charge,,. Charge means Ea charge asgim 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, '. • `"'""" '"' ' chargespending at the time of this application. If more than one party, or plea,ancludc traffc.snoIabons. Also list any ' please list charges by each individual's name. Commission must be notified of any arrests and/or convictions that may :'' occur after the date of signing this application. O YES © NO • •.,.':. If yes,please explain below or attach a separate page. •. ;�'' '— Date of Where Description . Name of Applicant Conviction Convicted of Disposition (nwilyyyy) (City&State)_ Charge . I. 2. Have you or your spouse svcr been approved or made application for a liquor license in Nebraska ori.,l • any other state? �;;; OYES ONO ' . :. IF YES,list the name of the premise(s): 3, Do you,as a manager,qualify under Nebraska Liquor Control Act(453-131.011 and do you intend to,.+.5 1. supervise,in person,the management of the business? ,.t (DYES ONO ; , ,,,; Form 103 ;!, Rovrtity2018•Ti Pato 4 of 6{'.^' 1. 2022-11-08 15:12 A 'V» 402 471 2814 P 5/9 4. List the alcohol related training and/or experience(when and where)of the person malting application. Q712022 Georgiana Amoura *NLCC Training Certificate Issued: Name on Certificate: Applicant Name Name of program(attach copy of course completion Onm/ DateYIY) certificate) Georgiana Amoura 07/2022 Responsible Beverage Service Training . *For list of MCC Certified Training programs see training Experience: Applicant Name/Job Title Date of ' Empl�rment: Name&Location of Business: • - - . 01crr C-*ccatr to Main 5i-Pric‘p. otioviif,jilLecog • f)tnersi11 vi f :. . . 5, Have you enclosed form 147 regarding fingerprints? EYES JNo t ` Form 103 Rev laly 2018 " Pose 5of6 I 1 1 L. w I etro-i55_,6-9-/-�- 5- ,���.,�-may�- 5, �. r ! .__ ' L .. 11(94 ri 110 AO 0 '1 cm 44 g ot- :,?.',4 ' .. Li x.. ..;"). " tu I ; Td 1,,„,. q k.--1 (5.23-1. $ t i.t.J eL (?.)WI z C) 2 N = .0 u) :,101 6�l 4 ,. i N pc:At4C;) I 0 * A 0 re ‘0 k.dk?) 0. it i t 2 c'_ (17 la,7,":"4 :**--1 0 > 4 0 4:1 ! E i r 1,1‘141 E - w M,' 'r W � Y YAA � wcn ry )1,144 y O w tc.,,fr,.)).5.1 c, ,y ak Q.' . 4 1111‘ X k:'.11- ...,3 ty.„,,,,,,.f .wy C�..�P ^r.` 4 r ` +awe� Tty ��� --- 14'..0 .,{� t::u«: i :Y�'.:`',. A a':A ;. � ul�,C.4iru'.:4LaW LT"i�r �'tal . " 41.�M e4:%. A IJ a fir _ Z6/66 d 41,9Z II, 20/ << .1 V 0:?1, 0g=Z6-220Z .1 .1 ,I N N se.. N 04 H 0 • I 1 I 1 O. 7.M r • 6 , i I,iw�. . r ` ^� N �.f C. `... 1 S ,,,, ^ rCi. a dry'+ 4.,' 2 d S.' 0 1r , 0 W. < 1 .�Q � !• 4 '..w. \ 1 L. 1— I % C..) N , ' I N co V W W 4 r 1.. G .. m . �..,�:. X • . rr� 1 • EL/EL d ' t68Z LLt ZOti << 6 d 6h:Z6 0£-EL-ZZOZ J 2022-11-08 15:12 A 1 >> 402 471 2814 P 6/9 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 453-131.01)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,a spousal 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. • Applicant Notification and Record.Challenge: Your fingerprints will be used to check the criminal history • • records of the FBI. You have the opportunity to complete or challenge the accuracy of the information • contained in FBI identification record The procedures for obtaining a change, correction, or updating.an • FBI identification record are set forth in Title 28, CPR, 16.34. i firIA1lr . .1P .4011. J Vatu 3 Manager cant tur f Spouse ill i attat Wet-) . . . . w „ ..,....: t.: ..„; ACKNOWLEDGEMENT ''' State of Nebraska County of `7o v, \�S The foregoing instrument was acknowledged before me this Noie-+ntikzt,e- 2 Ogg by r NAME OF PERSON EINGACRNOWLE GRD 4. 6 7 4r7.6:147t::2•1111•00001. A rix soar Gram Netosta , Notary Public signature '• .1M COMMJune 17,200 In compliance with the ADA,this application is available in other formats for persons with disabilities. •. A ten day advance period is required in writing to produce the alternate format. -, . :,;:} • Font 103 Rev July 2018' ' Paged of 6 2022-12-30 12:39 A 1 >> 402 471 2814 P 7/12 SPOUSAL AFFIDAVIT OF calm use RECEIVE NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION DEC :3 0 2022 301 CENTIINNLU.MALL SOUTH PO BOX 95046 LINCOLN,NE68509-s0d6 NEBRASKA LIQUOR {Mitt )471481 1 CONTROL COMMISSION Website:wwwJeemobrasios.gov 'ISA I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will not have any interest, directly or indirectly in the operation of the business (§53-125(13))of the Liquor Control Act. I will not tend bar,make sales,serve patrons, stock shelves,write checks, sign invoices,represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. The penalty guideline for violation of this affidavit is cancellation of the liquor license. I acknowledge that I am the applicant of the non participating spouse of the individual signing below. I understand that my spouse and I are responsible for compliance with the conditions set out above. 14 it is determined that m spouse has violated 53-125 13))the commission may cancel or revoke the liquor license, y p ($ ( 41111101h 11( 4a Signature of NON-PARTICIPATING SPOUSE '.: f CANT Hassan S. Amoura Georgiana L. Amoura Print Name Print Name State of Nebraska,County of DW ck,DcS State of Nebraska,County of,) v� The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me this 10\ Uf f l_At!'1 ., /1 f. `1(date) this , c `y`, , (2 2__(date) by QSCaiit\ PTY\U_U(O by b0\\C I Name of person acknowledged: Name oerson acknowl ged (Individual signing document) (Individual signing document) u N•: ,a. bile igaat r Notary P is Signature • Mt&NOTARY-G SEEK PPG-H Ga)NsSrasita CGx • Iv 1N COMMAt .Woks� 8 2023 *Comm.My C Cxp,0eloba mB;Z473 Io eompli.noo with rho ADA,this spousal affidavit atoms participation is ay.ilabio la other fort=for pawna with disabilities. A ten day adverse{period is requested in writing to produce the elteraoto fosnat. FORM 116 REV NOV 2016 PagcIt 2022-12-30 13:43 A 1` >> 402 471 2814 P 1/1 PRIVACY ACT STATEMENT/ Office Use only SUBMISSION OF FINGERPR NTS/ RECEIVED PAYMENT OF FEES TO NSF-Crn NEBRASKA LIQUOR CONTROL COMMISSION DEC 3 0 2022 301 CENTENNIAL MALL SOUTH NEtqAtAfrOtifilMOR PO BOX 9so46 N-���� � ' ��s�oN LINCOLN,NE 68509-5046 t)ct sta p any o e o owing pages PHONE:(402)471-2571 FAX:(402)471 2814 Website:www,lcc.nebraska.gov THISFOR.MJS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: DIRECTXONS FOR SUBMITTING_Il1T GERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REOUTRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make payment through the NSF PayPort online system at wymne,govigo/asp Or a check made payable to ME can be mailed directly to the following address: ***Please indicate on your payment who the payment is for(the name of the person being fingerprinted)and the payment is for a Liquor License*** The,Ncbr'aska State Patrol—CID Division 4600 I novation Drive Lincoln,NE 68521 • Fingerprints taken at NSP LI VESCAN locations will be forwarded to NSP—CID Applicant(s)will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application, Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedures for obtaining a change, correction,or updating a FIV identification record are set forth in Title 28, CFR, 16,34, ****Please Submit this form with your completed pplication to the Liquor Control Commission'""'** Trade Name Develotel Omaha LLC Residence Inn Omaha West Name of Person Being Fingerprinted: Georglana L.Amoura Date of Birth: Last 4 SSN: Date„fingerprints were taken: 1112022 Location where fingerprints were taken: Sherrltt Department How was payment made to NSP? ONSP PA'YPORT 8 CASH O CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous appli ation less than ago. \I SIG Q D OF PERSON BEING FINGERPRINTED ,1•; FORM 147 REV]U NE 2021 1/3/23, 10:11 AM Enterprise Mail-MANAGERS APPLICATION FOR OMAHA CITY COUNCIL HEARING-DEVELOTEL OMAHA, LLC • G1f Carman Johnson (CCIk) <carman.johnson@cityofomaha.org> MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING - DEVELOTEL OMAHA, LLC 1 message Carman Johnson (CCIk) Tue, Jan 3, 2023 at 10:11 <Carman.Johnson@cityofomaha.org> AM To: GEORGIANAA@immhotel.com Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <kimberly.pulliam@cityofomaha.org> Good morning RE: DEVELOTEL OMAHA, LLC The Omaha City Clerk's Office has received your application from the Nebraska • Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, JANUARY 31, 2023. City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. I ALSO NEED THE DATE OF BIRTH FOR GEORGIANA L. AMOURA. PLEASE SEND ME THIS INFORMATION AS SOON AS POSSIBLE. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk - 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax Carman.johnson@cityofomaha.org https://mai I.google.com/mai I/u/0/?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-4550560738667832748%7Cmsg-a%3Ar-5519593373... 1/2