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RES 2023-0398 - Appoint Michael J Kosalka manager of Hampton Inn & Suites Omaha Downtown, Homewood Suites Omaha Downtown �He sry n, • STATE OF NEBRASKA -.„-� �>>'o JimPillen , • NEBRASKA LIQUOR CONTROL COMMISSION d. .'f� Hobert B.Rupe y)iu•�dX*. �:Iti ��,,s Governor rr s^ Executive Director 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: March 21, 2023 From: Corrinne Andersen (corrinne.andersen@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: Apple Ten Hospitality Management Inc Trade Name (DBA): Hampton Inn & Suites Omaha Downtown, Homewood Suites Omaha Downtown License Number: C- 104601 and C-104602 Manager Name: Kosalka,Michael J Due Date: May 5, 2023 7 APPROVED n NO LOCAL RECOMMENDATION C DENIED COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) APPROVED C- 104601 - HAMPTON INN & SUITES OMAHA DOWNTOWN Clerk's Name: C- A' Date: April 19, 2023 Kim Lowe Bruce Bailey Harry Hoch Commissioner Chairman Commissioner An Equal Opporluniry Employer #29 RES#2023-0398 APRIL 18, 2023 • rw:-�. ,-��- °2°4 STATE OF NEBRASKA ai JimPillen NEBRASKA LIQUOR CONTROL COMMISSION q�, J s; Governor Hobert B.Rupe Ex• q'�4u:� 301 Centve Director ennial�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: March 21, 2023 From: Corrinne Andersen (corrinne.andersen@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: Apple Ten Hospitality Management Inc Trade Name (DBA): Hampton Inn & Suites Omaha Downtown, Homewood Suites Omaha Downtown License Number: C- 104601 and C-104602 Manager Name: Kosalka, Michael J Due Date: May 5, 2023 APPROVED n NO LOCAL RECOMMENDATION n DENIED COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) APPROVED C - 104602 - HOMEWOOD SUITES OMAHA DOWNTOWN • Clerk's Name: ,a•‘4E 'UZ 4 Date: April 19, 2023 Kim Lowe Bruce Bailey Harry Hoch Commissioner Chairman Commissioner An Equal Opportunity Employer #29 RES#2023-0398 APRIL 18, 2023 MANAGER APPLCATION sprwp,i.E. ,t -evat5.F,Tisiii .., 1:-.. FORM 103 k lq RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH Class: C, 1 PO BOX 95046 MAR. 0 3 202.3 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 License Number: - NEBRASKA LIQUOP -,- FAX(402)471-2814 kl 1:1 EMAIL:Iccirontdeskatnebnalcs,zov i aq LoOt 1; CONTROL COMMISSION ce wEasns:VAVW.Icc.nebraska.gov :. :d-iegikcslite MigtZ16:4,7-,d MINAGER MUST: bt• Be at least 21-years of age • Complete all sections of the application. i• Form must be signed by a member or corporate officer / dude Form 147—Fingerprints are required Provide a copy of one of the following:US birth certificate,US Passport or naturalization papers Be a resident of the state of Nebraska and be a registered voter in the State of Nebraska, p• in • Spouse who will participate in the business,the spouse must meet the same requirements as the manager ' applicant: Spouse who will not participate in the business Co etc the Spousal Affidavit of Non Participation(Form 116). Be sure to complete both halves of I . rt-......A'..?" • 0.:'.....2.:...:....104/14:0NOLRMOPM ,. • • Name of Corporation/LLC: Apple Ten Hospitality Management Inc. P.. :OW04 RIFOlettON • . : , • . .• Premises Trade Name/DBA: ibi-m.a-01J --intim ara s u tv-es ofm-iii-k —0,:x0.1-re)-04.1 Premises Street Address: I 2 12 illi tift i.'. Sr; City 40 ffii41#74 County: e*14!) 1,0 '.% Zip Code: Premises Phone Number YO 2- --Ili<'''' 5-5296 Premix m i eoti44t .‘ kt,.....tk.e... (1 U-14-44c.P. d d(A-t . . oy)p-o: SIGNA QUIRED BY CORPORATE OFFICER/MANAGING MEMBER The individual whose name is listed as a corporate officer or managing member as reported or listed with the Commission. I 1 • 1111 1 I 11 1111 I 1 I 2300002514 FORM 103 REV 12/212022 I-A PAGE 1 V ,1 0" MANAGER APPLCATION e t.:1(0. w jt3 1 t FORM 103 R RECPIVED 0. NEBRASKA LIQUOR CONTROL COMMISSION mem 301 CENTENNIAL MALL SOUTH Cass: PO BOX 95046 0-3 r 023 LINCOLN,NE 68509,5046 PHONE:(402)471-2571 License Number: 14 NEBRIEt,�„ la, .� R FAX:(402)a71-2814 CONTROL COMMISSION I'EMAIL:Icc.frontdeskla�nebraska.goy 16 7 , a; 41 WEBSITE:www.lcc.nebraslca.gov {:,, ..51--: ?a . ,_;.1 MAJ AGBR MUST: • Be at least 2I years of age • �• Complete all sections of the application. f Form must be signed by a member or corporate officer d • Include Form 147 Fingerprints art required Provide a copy of one of the following:US birth certificate,US Passport or naturalization papers Be a resident of the state of Nebraska and be a registered voter in the State ofNebraska, Spouse who will participate in the business,the spouse must meet the same requirements as the manager applicant•. S use who will not participate in the business t • Complete the Spo i Affidavit of Non Participation(Form 116). Be sure to complete both halves of this form. CWORATTON/4.4 INFORMAT-#. • Name of Corporation/LLC: Apple Ten Hospitality Management,Inc. Premises Trade Name/DBA: Aolocetikani Su;ts6, 0/44,1411 rA i' 4.L 1 Premises Street Address: 131 ti 4v wr.l b3 67 City: d!i t. County. st,t .5 Zip Code: 6K(O ,. Premises Phone Number: 4/047 3 '5*''' SI ay Premises (Y�i tt+.e. 1 `e k-4- 4ff,t4t_P•L4,0-k 1 SIG A REQUIRED BY CORPORATE OFFICER/MANAGING MEMBER The indi 'dual whose name is listed as a corporate officer or managing member as reported or listed with the Commission. _.._. - - -- ---- -- 2300002515 . FORM 103 btJtW REv 12/8R0221 A PAGE 1 k ;N'ARGLR INFO.4TXON Last Name: 1475A!k First Name: /f,cJt.r f - MI: 43 Home Address: .cgO3 J�fi ,►9v� '` I.-t'ZI GO City: Ali 4-0 4- t/ County: �)u;iv, Zip Code: > b�7 17 Home Phone Number: Y02— ' / -Z-7K , Driver's License Number: Social Security Number: Date of Birth: Place of Birth: (2P17/`7 f Emil address: /a C he.r h. ko,rr(14c ( $ b1M L 6,41 :YQa 1r},84 d?if y x: 114k.spopse'$:iifamn tiQ�►( veil `i:spouso aficlayi&114.:. epn sub m t ) YES XN0 Spouse's.i49..i. nat olt ' • • . . Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number: Date of Birth: Place of Birth: 'I1i Bi.S ( TJS 100tt 'LA1!]T . . . .. ' USE . YEAR AR CITY&STATE M OR CITY&STATEFRO M YEARPTO dIK k/ QS' Pres. FORM 103 REV 12/8/2022 PAGE 2 i►JA vA060$ .0.,T Q,EMPLO' ERS'. , ..` ,.'. ; : `.. '` f�.�, } 'YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER ?Oz( Zc Z �GAJdJ 64,1?,7t% Pro/ 71 Z-5zi-kite Zo1 J evzi 1...;04r44r-- e-- .S-SZf I. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and sponse, unless spouse has filed an affidavit of non- participation. Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge. Charge means ax 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, include traffic violations. Also list any charges pending at the time of this application. If more than one party,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. ❑ YES - ILL NO If yes,please explain below or attach a separate page. Date of Where Description Name of Applicant Conviction Convicted of Disposition (nnilyyYy) (City& Charge State) 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other slate? YES ONO IF YES,list the name of the premise(s): &O.-Vs ox,-f '? rrc 71.L4 s10.; ,/i#f W .Am , Vo.beorec 3. Do you, as a manager,vilify under Nebraska Liquor Control Act( 53-131.01) and do you intend to supervise,in person,the management ofthe business? 1j48 ONO FORM 103 REV 12/8/2022 PAGE 3 1 4. List the alcohol related training and/or experience(when and where)of the person making application. Applicant Name Date Name of program(attach copy of course completion (mtn/yyyy) certificate) 4 ' For list of NLCC Certified Training Programs see training Experience: Applicant Name!Job Title Date of Name&Location.of Business: Employment: i ZDi"i+Zstel aLpZ'iS*lffi—s% t76f—Tiv mt c� 1�v5�1 2,rvig-74sr1 Ilmtfou a CZ:,%ITV%/Alt.4 6t,Prect. IY)rci , bits 4 Ces t+144 4,A1.aehtj 5. Have you enclosed Form 147 regarding fingerprints? ®YES .INO FORM 103 REV 12/8/2022 PAGE 4 SIGNATURE PAGE—PLEASE READ CAREFULLY The undemigned applicant(s)hereby consent(s)to an investigation of his/her background and release present and future records of every kind and description including police records, tax records (State and Federal),and bank or lending institution records, and said applicant(s) and spouse(s)waive(s) any right or causes of action that said applicant(s) or spouse(s)may have against the Nebraska Liquor Control Commission,the Nebraska State Patrol,and any other individual disclosing or releasing said information. Any documents or records for the proposed business or for any partner or stockholder that ere needed in furtherance of the application investigation of any other investigation shall be supplied immediately upon demand to the Nebraska Liquor Control Commission or the Nebraska State Patrol. The undersignat understand andacknowledge that any license issued.used on the.information submitted in this application-is subject to cancellation ifthe information contained herein is incomplete.inaccurate or fraudulent, Applicant Notification and Record Challenge: Your finger,prints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the formation contained in FBI identification record. The procedures for obtaining a change,correction,or updating an FBI identification record are set forth in Title 28,CFR,1634. Must be signed by applicant and spouse. Signature``__ofAPPLICANT Signature of SPOUSE • Printed Name of APPLICANT Printed Name of SPOINg • FORM 103 REV 12/8/2022 PAGES PRIVACY ACT STATEMENT/ -::•` :s;: SUBMISSION OF FINGERPRINTS i REc IVED) i PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION MA ( .3 9"3 301 CENTENNIAL MALL SOUTH 95046 r.., ..,_.:.f . PO BOX � Wit" .-� _,��✓l:.). LINCOLN,NE 68509-5046 '- !C9 iTR•Q!. ;,{;;• ;f ,,$, .,14 .,•, PHONE: (402)471-2571 FAX:(402)471-2814 Website:www.lcc.nebraska.gov THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED 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 NSP PayPort online system at www.ne.gov/go/nsp Or a check made payable to NSP 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 Nebraska State Patrol—CID Division 4600 Innovation Drive Lincoln,NE 68521 • Fingerprints taken at NSP LIVESCAN 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 FBI identification record are set forth in Title 28, CFR, 16.34. ****Please Submit this form with your completed application to the Liquor Control Commission**** Trade Name Homewood Suites Omaha Downtown Name of Person Bein Fingerprinted: Michael Kosalka Date of Birth: last 4 SSNENE Date fingerprints were taken: February 2,2023 Location where fingerprints were taken: N 5 P io&`')--h- 1-- How was payment made to NSP? [ NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK 4 My fingerprints are already on file with the commission—fingerprints completed for a previous application less than 2 years ago?YES 0 SIGNA REQUIRED OF PERSON BEING FINGERPRINTED i-f-/di' FORM 147 REV JUNE 2021 3/21/23,9:32 AM Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HRG-APPLE TEN HOSP MNGMNT-2 LOCS GmailCarman Johnson (CCIk) <carman.johnson@cityofomaha.org> MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HRG - APPLE TEN HOSP MNGMNT - 2 LOCS 1 message Carman Johnson (CCIk) Tue, Mar 21, 2023 at 9:32 <Carman.Johnson@cityofomaha.org> AM To: "Kosalka, Michael" <michael.kosalka@hhmlp.com> Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <Kimberly.Hoesing@cityofomaha.org> Good morning RE: APPLE TEN HOSPITALITY MANAGEMENT, INC - 2 LOCS HAMPTON INN & SUITES HOMEWOOD SUITES The Omaha City Clerk's Office has received the Manager's application from the Nebraska Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, APRIL 18, 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 MICHAEL J. KOSALKA. 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 https://mai I.google.com/mail/u/0/?ik=cd387c45eb&view=pt&search=all&permthid=thread-a:r-4983559549759478147%7Cmsg-a:r-6188355835405988... 1/2