RES 2018-1105 - Class C liq lic to Holiday Inn Express Omaha City Clerk Office Use Only:
Publication Date November 26, 2018
RESOLUTION NO. 1105
Agenda Date: December 4,2018
Department: City Clerk
Submitter: Carman Johnson
CITY OF OMAHA
LEGISLATIVE CHAMBER
Omaha, Nebraska
RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
THAT, in accordance with the provisions of the Nebraska Liquor Control Act, as
amended, after a hearing held within 45 days after receiving notice and a copy of the license
application and upon due consideration of all standards and criteria provided by law,this
Council hereby recommends that the following application for a Class "C" Liquor License
be granted.
Farnam Lodging, L.L.C., dba"Holiday Inn Express Downtown Omaha", 2431 Farnam Street.
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That, the cost of publication of notice of the hearing was $26.00.
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Adopted: December 4, 2018 7-0
Attest: •
City Clerk
Approved: S - ,
Mayor
R. 1I0S
C- 122853
TYPE OF LICENSE: CLASS"C" LIQUOR LICENSE
NAME&ADDRESS: FARNAM LODGING,L.L.C.
DBA"HOLIDAY INN EXPRESS DOWNTOWN OMAHA"
2431 FARNAM STREET
RECEIVED: OCTOBER 30,2018 •
45TH DAY: FRIDAY, DECEMBER 14,2018 /
HEARING DATE: DECEMBER 4,2018-35T DAY ti
AND/OR PERSONS CONTACTED: KIRTI TRIVEDI
402-933-6959
ATTORNEY-DARRELL STOCK
402-474-8690
POSTED: JJ-I b -J Y
NOTIFIED: )/ av-il-
NEW APPLICATION,NEW LOCATION.
ZECEIPT 10-26-2018
NEBRASKA LIQUOR CONTROL COMMISSION
From: TRACY BURMEISTER
OCT 30'16 rMB:50
City Clerk Omaha HE-RCVD
Email: TRACY.BURMEISTER@nebraska.gov
Phone: (402) 471 - 2572
Fax: (402) 471 - 2814
Email l: City Clerk of Omaha— carman.johnson@cityofomaha.org
Applicant: Farnam Lodging LLC dba Holiday Inn Express Downtown Omaha
License #: Class C-122856
Please sign and date stamp this receipt and return back to the NLCC office
4A
Date of Receipt of Application
criCL*Id/V
Signature
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APPLICATION FOR LIQUOR LICENSE RECEIVED
CHECKLIST-RETAIL •
NEBRASKA LIQUOR CONTROL COMMISSION
PO BOX
OX9 XIALMALLSOUTH OCT 25 20i8
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814 NEBRASKA LIQUOR
Website:www.lcc.nebraskx.gov • °NT ,(-OPA cing# N
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Hot List: YES O I New eplacing#
Class Type 122853 Initial
Farnam Lodging, L.L.C.
Applicant name
Trade name Holiday Inn Express Downtown Omaha
Previous trade name
Contact email address andrea.holmstedt@anantops.com [Andrea Holmstedt]
Provide all the items requested. Failure to provide any item will cause this application to be returned or placed on
hold. All documents must be legible. Any false statement or omission may result in the denial, suspension;
cancellation or revocation of your license. If your operation depends on receiving a liquor license, the Nebraska
Liquor Control Commission cautions you that if you purchase, remodel, start construction, spend or commit money
that you do so at your own risk. Prior to submitting your application review the application carefully to ensure that
all sections are complete, and that any omissions or errors have not been made. You may want to check with the
city/village or county clerk, where you are making application, to see if any additional requirements must be met
before submitting application to the Nebraska Liquor Control Commission.
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Office use only tI
PAYN F..11'1''I.Ypf_ Pa/Le/Part
_ /1eJ
AMOUNT:--_—% III III II 1101 III III III II
1800013026
FORM 10( Illl
REV FEB 201;
1
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1. X Fingerprints are required for each person as defined in new application guide, found on our website under
"Licensing Tab"in"Guidelines/Brochures". See Form 147 for further information,this form MUST be included with .
your application.
2. X Enclose application fee of $400 (nonrefundable), check made payable to the Nebraska Liquor Control
Commission or you may pay online afPAYPORT -- _...... .. ....._.....__-.. . ._.._...._.. .___.._.... ......
3. X Enclose the appropriate application forms;
• Individual License(requires insert form 1)
Partnership License(requires insert form 2) •
Corporate License(requires insert form 3a&3c)
Limited Liability Company(LLC)(requires form 3b&3c)
4. N/A if building is being leased send a copy of signed lease. Be sure the lease reads in the name of the individual(s),
corporation or Limited Liability Company(LLC)making application. Lease term must run through the license year
. being applied for.
5. X - If building is owned or being purchased send a copy of the deed or purchase agreement in the name of the
applicant.
6. N/A If buying the business of a current liquor license holder:
a. Provide a copy of the purchase agreement from the seller(must read applicants name)
b. Provide a copy of alcohol inventory being purchased(must include brand names and container size)
c. Enclose a list of the assets being purchased(furniture,fixtures and equipment)
7. N/A If requesting to operate on current liquor license;enclose Temporary Operating Permit(TOP)(Form 125).
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8. N/A Enclose a list of any inventory or property owned by other parties that are on the premises.
9. x For citizenship enclose U.S.birth certificate;U.S.passport or naturalization paper
a. For residency enclose proof of registered voter in Nebraska •
b. If permanent resident include Employment Authorization Card or Permanent Resident Card
c. See guideline for further assistance
)0. y Corporation or Limited Liability Company(LLC)must enclose a copy of articles of incorporation;as filed with
the Secretary of State's Office.
11. X Submit a co.y of your business plan.
I acknowledge 1 is applies I is '-: guarantee that a liquor license will be issued to me, and that the average
processing p• 1: is 60 days F Trmore, I understand that all the information is truthful and I accept all
responsibil .or any false do ' I en .. ,
aerei
S
r rnpii,Man.W.ber •� -
._ . C:.. — xi i" i
Date 1.
t
f.
FORM 100
i
• REV FEB 2017 t
PAGE 2 k
1
APPLICATION FOR LIQUOR LICENSE
RETAIL RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUI'II OCT2 <; 2018
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 - NEBRASKA LIQUOR
FAX:(402)471-2814 •
Website:wwwlcc.nebraska.govi CONTROL COMMISSION
CLASS OF LICENSE FOR WHICH APPLICATION IS MADE AND FEES
CHECK DESIRED CLASS
RETAIL LICENSE(S) Application Fee$400(nonrefundable)
A BEER,ON SALE ONLY
B BEER,OFF SALE ONLY
XX C BEER,WINE, DISTILLED SPIRTS,ON AND OFF SALE
D BEER, WINE, DISTILLED SPIRITS,OFF SALE ONLY
BEER, WINE,DISTILLED SPIRITS,ON SALE ONLY
J LIMITED ALCOHOLIC LIQUOR,OFF SALE—MUST INCLUDE SUPPLEMENTAL FORM 120
AB BEER,ON AND OFF SALE
AD BEER ON SALE ONLY,BEER,WINE,DISTILLED SPIRITS OFF SALE
IB BEER,WINE, DISTILLED SPIRITS ON SALE,BEER OFF SALE ONLY
Class K Catering license(requires catering application form 106) $100.00
Additional fees will be assessed at city/village or county level when license is issued
Class C license term runs from November 1 —October 31
All other licenses run from May 1 —April 30
Catering license (K)expires same as underlying retail license
CHECK TYPE OF LICENSE FOR WHICH YOU ARE APPLYING
Individual License(requires insert 1 FORM 104)
Partnership License(requires insert 2 FORM 105)
Corporate License(requires insert 3a FORM 101 &3c FORM 103)
XX Limited Liability Company(LLC)(requires form 3b FORM 102&3c FORM 103)
NAME OF ATTORNEY OR FIRM ASSISTING WITH APPLICATION(if applicable)
Coulniission will call this person with any:questions We`may'haveon thisapplication
Name Darrell K.Stock,Attorney;Brenda Black,Legal Assistant Phone number: 402-474-8690
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Firm Name Darrell K.Stock,P.C.,L.L.O.
553-3 S& a71-1t 5��
I ✓Icd1n , Afc In b'Sl � )
�-/ FORM 10t
REV FEB 201;
PREMISES INFORMATION
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Trade Name(doing business as) Holiday Inn Express Downtown Omaha
Street Address#1 2431 Farnam St.
Street Address#2
City Omaha County Douglas Zip Code 68102
Premises Telephone number_No number at this time
Business e-mail address andrea.holmstedt@anantops.com
Is this location inside the city/village corporate limits: YES X NO
Mailing address(where you want to receive mail from the Commission)
Name Kirti K.Trivedi
Street Address#1 PO Box 3847 i.
Street Address#2
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City Omaha State NE Zip Code 68103-0847 •
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DESCRIPTION AND DIAGRAM OF THE STRUCTURE TO BE LICENSED
TREAD CAREFULLY •
In the space provided or on an attachment draw the area to be licensed. This should include storage areas,basement, outdoor
area, sales areas and areas where consumption or sales of alcohol will take place. If only a portion of the building is to be
covered by the license,you must still include dimensions(length x width)of the licensed area as well as the dimensions of the
entire building. No blue prints please. Be sure to indicate the direction north and number of floors of the building.
**For on premises consumption liquor licenses minimum standards must be met by providing at least two restrooms ff
Building:length 200 x width 67 in feet
Is there a basement? Yes No x If yes,length x width in feet
Is there an outdoor area? Yes No x If yes,length x width in feet
PROVIDE DIAGRAM OF AREA TO BE LICENSED BELOW OR ATTACH SEPARATE SHEET
See attached Diagram
4h:
FORM 10(
REV FEB 2011
FARNAM LODGING,L.L.C.
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
2431 FARNAM ST.
OMAHA,NE 68102
T
N
Five Story Hotel approximately 200' long and 67' wide
with no basement and no outside area
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1j
aTY OF OMAHA THE DAILY RECORD
PUBLIC HEARING NOTICE OF OMAHA
NOTICE IS HEREBY GIVEN that the thy
Council of Vie City of Omaha, Nebraska, will LYNDA K. I ENNINGSEN, Publisher
hold public hearings on December 4, 2018,
at 2:00 PM In lOmaha,a Chambers 1819 PROOF OF PUBLICATION
Famam Street, Omaha, Nebraska .
The purpose of these hearings is to consider
approval of: •
UNITED STATES OF AMERICA,
Cass-r Liquor License for FamamLodging, The State of Nebraska, l
LLC., dba 'Holiday Inn Express Downtown 188.
Omaha", located at 2431 Famam Street District of Nebraska,
Class "Cr Liquor License for anseth County of Douglas,
Hospitality Company, Inc, dba "Element City of Omaha,
Omaha Midtown Crossing", located at 3253
Dodge Street,Suite 1103.
J.BOYD
Gass 'r Liquor license for MPLS Hotel
Management,
located Ltd., dba
a1 5"Omaha Ramada being duly sworn,deposes and says that she is
heet
Cass"C'Liquor License for Nolghts, LLC,' LEGAL EDITOR
dba 'Pub'134; located at 3015 North 904
Street as. of THE DAILY RECORD, of Omaha, a legal newspaper,printed and
Class •r Liquor License for euenaVida published daily in the English language, having a bona fide paid
LLC, dba •Epoo Cantina; located at 1101' circulation in Douglas County in excess of 300 copies, printed in
Davenport Street Suite 150. Omaha,in said County of Douglas,for more than fifty-two weeks last
Class 'r Liquor license for IRC II, Inc, past; that the printed notice hereto attached was published in THE
dba'The Aboretum, located at 8141 Famam
Drive. DAILY RECOrRRt.of op
Class
•D'Liquor License for Neva Corner 1`tovem r 6r 1018
Store,LLC,dba'Aroma Corner Store', located
at 5522 South 30"Street.
Anyone Interested in these matters or
desiring to give evidence in support of or In
protest against the Issuance of such license
should be In attendance at this meeting. That said Newspaper during that time was v ,Halted and
Elizabeth Buns,cMc in general circulation in,the=aunty of Do i :: (�;,r;,i of Nebraska
City Clerk It GENERAL NOTARY-State of Nebraska parr.
Cry of Omaha 7 ELLEN FREEMAN OF
11-26-18 ersh1-. My Comm.Exp.De 6 peerr III,2021 Subscribed in ni/g >.:.nee and sworn to before
Publisher's Fee $ m' day of
Additional Copies $ AIr November 20 8
,ice $36.50 Vile
c otary Public in and for Douglas County,
State of Nebraska
(Please publish in the Daily Record on November 26, 2018)
Please charge to General Order NO. 2447 H
CITY OF OMAHA
PUBLIC HEARING NOTICE
NOTICE IS HEREBY GIVEN that the City Council of the City of Omaha, Nebraska, will hold a
public hearing on December 4, 2018, at 2:00 PM in Legislative Chambers, 1819 Famam Street,
Omaha,Nebraska 68183. The purpose of this hearing is to consider approval of a Class "C"
Liquor License for Farnam Lodging, L.L.C., dba"Holiday Inn Express Downtown Omaha",
located at 2431 Famam Street.
Anyone interested in this matter or desiring to give evidence in support of or in protest against
the issuance of such license should be in attendance at this meeting.
Elizabeth Butler, CMC
City Clerk
City of Omaha
DECEMBER 4, 2018—RES # J ) DS MOTION BY J [ n TO GRANT
SECONDED BY 1710;7
APPROVED1
•APPLICANT INFORMATION
1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY§53-125(5)
Has anyone who is a party to this application,or their spouse,EVER been convicted of or plead guilty to any charge. Charge k
means any 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. Also
list any charges pending at the time of this application. If more than one party,please list charges by each individual's name.
Include traffic violations. Commission must be notified of any arrests and/or convictions that may occur after the date of
signing this application.
X YES _ NO
If yes,please explain below or attach a separate page
Name of Applicant Date of Where Description of Charge Disposition
Conviction Convicted
(mnn/yyyy) (city&state) F
See attached •
2. Are you buying the business of a current retail liquor license?
YES X NO
If yes,give name of business and liquor license number
a)Submit a copy of the sales agreement
b)Include a list of alcohol being purchased, list the name brand,container size and how many
c)Submit a list of the furniture,fixtures and equipment
3. Was this premise licensed as liquor licensed business within the last two(2)years?
YES X NO
If yes, give name and license number I
4. Are you filing a temporary operating permit(TOP)to operate during the application process?
YES X NO
If yes:
a) Attach temporary operating permit(TOP)(Form 125)
b) TOP will only be accepted at a location that currently holds a valid liquor license.
FORM 10(
REV FEB 2O1;
FARNAM LODGING, L.L.C. .
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
2431 FARNAM ST. •
OMAHA,NE 68102
ATTACHMENT TO RETAIL APPLICATION FOR LIQUOR LICENSE RESPONSE TO QUESTION 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 charge. Charge means any 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.Also list any charges pending at the time of this application.If more than •.
one party,please list charges by each individual's name.
Who Date of Conviction Where Convicted Description of Charge Disposition
mm/yyyy City&State -
Deepak Gangahar I1/12/2002 Sarpy County,NE Speeding Dismissed
9/15/2000 Sarpy County,NE Speeding Dismissed •
10/23/2013 Douglas County,NE Red Light Guilty Plea by Waiver
. 5/31/2011 Lancaster County,NE Speeding Guilty Plea by Waiver
7/2/2012 Lancaster County,NE Improper Registration Guilty Plea by Waiver •
3/29/2016 Fillmore County,NE Speeding Guilty Plea by Waiver
2/18/2014 Sarpy County,NE Disobey stop lights Guilty Plea by Waiver
Kiran Gangahar 2/1/2002 Cass County,NE No valid registration Guilty plea by waiver
4/21/2009 Omaha,NE Speeding Guilty plea by waiver
9/15/1995 Lincoln,NE Speeding/no seat belt Guilty plea by waiver
8/11/2010 Otoe County,NE Speeding Guilty plea by waiver t
Kirti K.Trivedi 10/4/2016 Douglas County,NE (1)DUI 3`d Offense Preliminary Waived bindover k
(2)Refusal to District Court (4
4/11/2017 Douglas County,NE DUI 3rd Offense Guilty Plea/Admission in
Court
21/21/2015 Douglas County,NE No Valid Registration Guilty Plea by Waiver
12/17/2014 Lancaster County,NE Improper Registration Dismissed by Prosecutor
12/27/2000 Kearney,NE (I)Leave accident (I)Dismissed
(2)Willful reckless drive amended to (2)Guilty plea by waiver
Careless
8/12/2003 Lincoln,NE Fail to deliver title on sale/No proof of Dismissed
Ins./No valid license
12/7/2005 Lincoln,NE (I)DUI (I)Guilty k'
(2)Drive on Suspended license (2)Dismissed
(3)Negligent Drive (3)Dismissed
4/19/2007 _ Lincoln,NE Drive on Suspended license Guilty
8/28/2008 Omaha,NE (1)DUI (1)Guilty
(2)Drive during revocation r (2)Dismissed
10/15/2001 Hall County,NE Speeding Guilty plea by waiver
7/20/2001 Seward County,NE Speeding Guilty plea by waiver
4/22/2003 Seward County,NE Speeding Guilty plea by waiver
3/14/2005 Lincoln,NE Speeding . Guilty plea by waiver
11/1/1999 Adams County,NE Speeding Guilty r
12/6/2001 Rede Willow County, Speeding Guilty plea by waiver
4/9/2003 Cheyenne County,NE No valid registration License suspended to failing
to appear
10/27/2004 Adams County,NE Speeding Guilty plea by waiver
12/2/2004 Harlan County,NE Speeding Guilty plea by waiver
9/11/2000 Furnas County,NE Speeding Guilty plea by waiver
1/25/2005 Gosper County,NE Speeding Guilty plea by waiver
3/1/1996 Denver,CO (1)Disturbing the Peace (I)Dismissed
(2)Trespass (2)Dismissed
824/1997 Pueblo,CO (I)Disorderly Conduct (I)Guilty Plea
(2)Damage Property (2)Guilty Plea ,
(3)Public Peace/Possession of Liquor (3)Guilty Plea •
3/26/1998 Pueblo,CO Criminal Mischief$400-$15,000 Dismissed
8/27/98 Pueblo,CO Criminal Mischief$I00-$400 Dismissed
Seems Trivedi 1 Unknown I California Traffic violation Unknown •
FARNAM LODGING,L.L.C.
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
2431 FARNAM ST.
OMAHA,NE 68102
ATTACHMENT TO RETAIL APPLICATION FOR LIQUOR LICENSE RESPONSE TO QUESTION 11:
List all past and present liquor licenses held in Nebraska or any other state by any person named in this
application. Include license holder name,location of license and license number. Also list reason for
termination of any license(s)previously held.
f
License Licensee Name Applicant
No.
Unknown Firethom Golf Club Gangahar was a
. previous partner
#082018 LNK Lodging,LLC d/b/a Holiday Inn Express&Suites Lincoln Trivedi
Class I Airport • Gangahar
#087982 Tamarin Lodging,LLC d/b/a Holiday Inn Lincoln Southwest Trivedi
Class I (formerly Aura,Inc. d/b/a Aura Restaurant& Bar) Gangahar
#082019 Husker Management,Inc. d/b/a Holiday Inn Express Suites Trivedi
Class I Lincoln Southeast
#099259 DMK Union General Partnership d/b/a Holiday Inn Downtown Trivedi
Class CK Omaha(DMK Investments&Kut Partners) Gangahar
#117353 24th Street Enterprises,LLC d/b/a Even Hotel Downtown Omaha Trivedi
Class C Gangahar
#121343 LNK2 Lodging,LLC d/b/a Fairfield Inn&Suites—Lincoln Trivedi
Class C Airport Gangahar
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5. Are you borrowing any money from any source,include family or friends,to establish and/or operate the business?
X YES NO
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If yes, list the lender(s) Veridian Bank
6. Will any person or entity,other than applicant,be entitled to a share of the profits of this business?
YES X No
If yes,explain. (all involved persons must be disclosed on application) .
•
No silent partners
7. Will any of the furniture, fixtures and equipment to be used in this business be owned by others?
YES X NO
If yes, list such item(s)and the owner.
8. Is premises to be licensed within 150 feet of a church,school,hospital,home for the aged or indigent persons or for
veterans,their wives,and children,or within 300 feet of a college or university campus?
YES X NO •
If yes,provide name and address of such institution and where it is located in relation to the premises(Neb.Rev. Stat.
53-177)(1)
Provide letter of support or opposition,see FORM 134—church or FORM 135-campus
9. Is anyone listed on this application a law enforcement officer?
YES X NO
If yes, list the person,the law enforcement agency involved and the person's exact duties.
10. List the primary bank and/or financial institution(branch if applicable)to be utilized by the business.
a)List the individual(s)who will be authorized to write checks and/or withdrawals on accounts at this institution.
Pinnacle Bank,Kirti K.Trivedi
11. List all past and present liquor licenses held in Nebraska or any other state by any person named in this application.
Include license holder name, location of license and license number. Also list reason for termination of any license(s)
previously held.
See attached list
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FORM 10(
REV FEB201; j,
12. List the alcohol related training and/or experience(when and where)of the person(s)making application. Those persons
required are listed as followed:
• Individual: Applicant and spouse;spouse is exempt if they filed Form 116—Affidavit of Non-Participation.
• Partnership: All partners and spouses,spouses are exempt if they filed Form 116—Affidavit of Non-Participation.
• Limited Liability Company: All member of LLC,Manager and all spouses;spouses are exempt if they filed Form
116—Affidavit of Non-Participation.
• Corporation: President, Stockholders holding 25%or more of shares,Manager and all spouses;spouses are exempt if
they filed Form 116—Affidavit of Non-Participation.
NLCC certified training program completed:
Applicant Name Date Name of program(attach copy of course completion certificate)
( Yn N)
Kirti K.Trivedi n/a Is not responsible for selling or buying alcohol for the hotel:
Deepak M.Gangahar rila He is not involved in the day to day operation of the hotels
and fe
training program
List of NLCC certified training programs
Experience:
Applicant Name/Job Title Date of Name&Location of Business
Employment:
2009 Husker Management,Inc.d/b/a Holiday Inn Express&Suites Lincoln Southeast
Kirti IC Trivedi 2012 DMK Union Central Partnership dba Holiday Inn Downtown Omaha(DMK Investments&Kirt Part
s0i3 Taniann Lodgmi,LLC a/b/a holiday inn Lincoln Southwest tformeny Aura,Inc arm Auraltesraurat
President,Co-Owner/Managing Member of the 2016 LNK Lodging,LLC d/b/a Holiday Inn Express&Suites Lincoln Airport
e t4ar r t d Id h haw•Add ng"...licenses Rnm 201a 2dth e. E_.e.__i. ,.n dn.r.,x• .._v_..l D wntown Omaha
the year set forth to the present 2017 LNK2 Lodging,LLC d/b/a Fairfield Inn&Suites—Lincoln Airport
13. If the property for which this license is sought is owned,submit a copyof the deed,orproof of ownership. If leased,
P P rtY gh P £
submit a copy of the lease covering the entire license year. Documents must show title or Lease held in name of
applicant as owner or lessee in the individual(s)or corporate name for which the application is being filed.
Lease: expiration date
X Deed
Purchase Agreement
14. When do you intend to open for business? October 31,2018
15. What will be the main nature of business? Hotel with Market and Social Activity/Event Areas
16. What are the anticipated hours of operation? 6 a.m.to 2 a.m.
17. List the principal residence(s)for the past 10 years for all persons required to sign,including spouses.
RESIDENCES FOR THE PAST 10,YEA.RS,APPLICANT AND SPOUSE MUST:COMPEETE:
APPLICANT:CITY&STATE YEAR SPOUSE.CITY&STATE YEAR
FROM TO FROM TO
Kirti K.Trivedi: Omaha,NE 2007 Present Seema Trivedi: Omaha,NE 2009 Present
San Pablo,CA 2006 2009
Deepak M.Gangahar: Omaha,NE 2015 _Present Kiran Gangahar: Omaha,NE 2015 Present
Lincoln,NE 1984 2015 Lincoln,NE 1984 2015
If necessary attach a separate sheet.
•
FORM 10(
REV FEB201;
The undersigned applicant(s)hereby consents) to an investigation of his/her background and release present and future records of every kind and
• • description including police records,that records(Slate and Federal),and hank or loading 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
are 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 undersigned understand and acknowledge that any license issued%based on the Information_
atbmined in this application is subject to cancellation if the information cnntain-A herein is inromniete inaccurate or fraudulent
Individual applicants agree to supervise in person the management and operation of the business and that they will operate the business authorized by the
license for themselves and not as an agent for any other person or entity. Corporate applicants agree the approved manager will superintend inperson the
management and operation of the business. Partnership applicants agree one partner shall superintend the management and operation of the business. All applicants agree to operate the lireneed business within all applicable laws,rules,regulations,and ordinances and to cooperate fully with any authorized
agent of the Nebraska Liquor Control Commission.
•
Applicant Notification and Perot, halleage.• Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the.. .•y of the information contained in FBI Identification record The procedures far obtaining a change,correction,or
updating an FBI identifte, cord are set forth in Title 28,CFR, 16.34.
Must be signed in th jr ce of a notarypublic by applicants)and spouse(s). Ste guideline forrequved si0 10
Il
7 vl
• Sig cast U ]
/ gnamre of se
I� rli K. Trivedi _ Seema Trivedi
Print Name Print Name
Signature of Applicant
Signature of Spouse
Print Name
Print Name
•
ACICNOwLEDGFNT
• State ofNebras
((County of (ty,„.c_.4. 4ti The foregoing instrument was acknowledged
�before me this
S . Le, / 7� )ao f d by r6 A /(it✓ONr' t.c.¢?y M II4)Oif/t� I
name of patents)acknowledged(individunl(s)signing) i
F
No ry b is ignature rm.—
C.
S of t...%O BBurm a
PAY 'silo v .. :-7 t
. G
d
I
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, [f
I
FORM 700
REV FEB 2017
PAGE8
• The undersigned applicants),hereby cinscnt(4 to an investigation of his/her background and release present and future records of every kind arid
description includingpolice records,tax remade(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
. are needed in furtherance of the application investigation of anyother investigation
shalt be supplied iaonethately upon demand In the Nebraska Liquor teethed Commission or the Nebraska State Patrol. The rmdersigned understand and,acknowledge-that-my.license-issued.based on the Information
aubmmed in this anolicanon ss suhi t to alletion iTthe i f do oat L ed h e' i '
Individual applicants agree to supervise in person the management and operation of the business and that they will operate the business authorized by the lictmse for themselves and not as an agent Tor any other person or entity. Corporate applicants agree the approved manager will superintend in person the
management and operation of the business. Partnership applicants agree one partner shall superintend the management and operation of the business. All applicants agree to operate the licensed business within all applicable laws,rules,regulations,and ordinances and to cooperate fully with any authorized
. agent of the-Nebraska Liquor Control Commission.
Applicant Notification and Record Challenge; Your jrngerprintr will be aced to check the criminal history reisorde fMUM, You hoe the opportunity
to complete or challenge the accuracy of the irjotmarioa canlabiedEn FBI idend)fcnrinn record. The pmcedures for obtaining a change.correction.or updating on FBI identification record are set forth in Title 28,CFR,16.34.
Must be si the presence of a notary public by applicant(s)and spause(s). See guideline for required signatures.
Signature of Applicant I` Signature of Spoon �-
EPPrE_' M. �A-NG'AMP & k; kpA 6631-NR1-115) Q.
Print Name - Print Name
Signature of Applicant Signature of Spouse •
•
Print Name Plnt Namei.
I
F
f
ACKNOWLEDGEMENT
State of Nebraska //
County of / /q„s,C-u-S 4,) q� The foregoing instrument was acknow�)eedged before me this/ Ir
SAP . .lade / 7 do/ /f by ✓� Qp (C s /S • /t vie 4114r`
a pats (s acknowledged us ,v,dea s)sign g) T_ k
4YCSI
S}ayabiBV Ai:a'
agues
Ma 5104
•
•
in compliance with the ADA,this application is available in other formats for persons with disabilities.
A ten day advance period is rn uimd in wn ring to produce the altcmalc format.
FORM 100 •
REV FEB 2017
PAGE3 F
I
(
•
a•
SPOUSAL AFFIDAVIT OF OficeUse 0ECFEgt WED
NON PARTICIPATION INSERT
{ NEBRASKA LIQUOR CONTROL COMMISSION 5 301 CENTENNIAL MALL SOUTH C2 f P •
PO BOX 95046 L U
LINC0LN,NE 63509 5046 a,�r-p(� pl� /, +
_....... ._:FAX:(42)471- IV.CDR- Jr',/y-rc)C! r'
JJrt
' Fwabsne.Owww.lccnebnska.gav CONTROL f' C
oa�r�►su�oni
•
I XI 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.
X I acknowledge that I ant the applicant of the non-participating spouse of ,- individual signing below. I
understand that my spouse.'. I are responsible for compliance with to c o Mons
set out above. If, it is
determined that my spews,
'plated(§53-125(13))the commission • a .ncel or revoke the liquor license.
i I'
k
Signa -- of. : '-PARTrPATINGSPOUSEali
�/ ofAP'
I
Seema Trivedi Kirti K.Trivedi
Print Name Print Name
State of Nebraska,County of (4, risk State of Nebraska,County of C!-t,C 4-7 i
i
i
• The foregoing instrument was acknowledged before me The foregoing instrument was
acknowledged before me
�.this iir a7j r (date) this c - -/L... // „2'4/t (date) t
�'1 I
bYA /fin a (A/ by l/'�J'(`r ///'r.!
Name of person acknowledged Name of person acknowledged
(Individual signing document) (Individual signing document) L
14,z r�J
Notary Public Signature Nota . • 't.dag re
Ney�a BLACK-General
Sfded Bastinu Is
Staff Ol61 ke-t AT Notary
BRE Co'"' x Seal
June 5,2020my Gonunksico G1n
•
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities. •
A ten day advance period is requested in writing to produce the alternate format. tt
FORM 116
REV NOV 2016
Page I 1
i
SPOUSAL AFFIDAVIT OF Office Use ,
NON PARTICIPATION INSERT •
2
• NE'nRASKA LIQUOR CONTROL COMMISSION OCT S 2:''.f8
301 CENTENNIAL MALL SOUTH
• PDBOX95044
LINCOLN,NE NEBRASKA LO R
AO4 71-2S I
FAX:( 02)471-28!4 CONTROL COMMISSION N
'Webs,te: wwwicc.nebnsta.gov
X F I acknowledge that I am the spouse of a liquor license bolder. 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 x
• Act. T 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 X 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. If, it is
determined that my spouse has violated(§53-125(13))the corn,t }Ssion may cancel or revoke the liquor license.
4:6( �
Signature of NON-PAR7TCIPATIIN'G SPOTISE Si a attire of APPLICANT
Kiran Gangahar Deepak M.Gangabar
Print Name / Print Name
State of Nebraska,County of f fen. State of Nebraska,County of f L,_
The foregoing instrument was acknowledged before me The foregoing
/instrument was acknowledged before me
this .Sg4ft .. / 71 ,2O/$ (date) this K,t,nW--,L .. /7, r (date)
•
•
•
by f of p tl�+. by N�-pG�//1 rjaw-47414,Nam
e of erso clm ]edged Na a oYperson acvule ged
(Individual si ing document) (Individual signing document)
.Notary Pub lc ignat6re No : • • ' . -7.7.
Inc
StatsofNabrasilt- :
gp�ADBIACK
. ..8)1110 3{bWts t amoriail
1 .
I;RENDpDB1ACK
MYciroglar
N compliance with the AQA,this speusal dEdavitetuc=,atde%p_tion is mailable in dyes fema!sfos pm=wi9t d�ab:tides.
A ten dayadvwoe period is requested in writing so produce the alternate fomat.
FORM 116
RFV NOV 2016
Page-I I
APPLICATION FOR LIQUOR LICENSE Office Ilse RECEIVED 1
LIMITED LIABILITY COMPANY(LLC)
• INSERT-FORM 3b
0L 2! uZQi?
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENfENNIALM MALL
➢DX95046 — -- .._.. NEBRASkh k 1.40R .
PHONE: 02)4712571 6
CONTROLCOMMISSION
LINCOLN,N 47109-5
FAX:(402)471-2a14
Website:www lec nebnska.aov
All members including spouse(s),are required to adhere to the following requirements:
1) All members spouse(s)must be listed
4 2) Managing/Contact member and all members holding over 25%interest and their spouse(s)(if applicable)must submit .
fingerprint'.See Form 147 for further information,this form MUST be included with your application.
3) Managing/Contact member and all members holding over 25%shares of stock and their spouse(if applicable)must sign
the signature page of the Application for License form 100(even if a spousal affidavit has been submitted)
Name of Registered Agent: Darrell K. Stock
Farnam Lodging, L.L.C.
LLCAddress:222 S. 15th St., Suite 401N
City:Omaha state:NE ZipCode:68102
LLC Phone Number: 402-933-6959 LLC Fax Number402-614-1867
..fi�xx) ����r '1 WA' ' ["Cb - k 4h i
•
Trivedi Kirti K.
Last Name: First Name: MI:
HomeAddreaa:2211 S. 64TH PLAZA, APT 234 city.Omaha
State:NE z Code:68106 Home Phone Ntlmber:402-432 4863 (cell)
t
i
gnature of Managing/Contact Member f
ACKNOWLEDGEMENT
State of Nebraskgr
County of I is r a . The fore oing Intro eat was acknowledged before me this
r-t//7!
:' s. ' moot person acknowledge i
I / .: 0 I�A ARx Seal 1
MS of Nebraska-General Note,/
DRENDAD D1ACK '
My CpmmleebnEKp ea
Juno 6,2020
1
f
FORM 102
REV NNE 21315
Page 1 of4 1
List names'of all members and their spouses(even if a spousal affidavit has been submitted)
Last Name:Tried i First Name:Kit MI:K.
Social Security Number: - - - -- - - - - Date of Birth. -- - - - -
Spouse Full Name (indicate N/A if single):See ma Trivedi
Spouse Social Security Number: - - - - - Date of Birth:----. - - -. -
Percentage of member ownership 3 0%
LastName:Gangahar FirstName:Deepak mi:M.
Social Security Number: - - -' ' ' Date of Birth: " ' -" '-
Spouse Full Name(indicate N/A if single):Kiran Gangahar
Spouse Social Security Number: - - - - - - Date of Birth:-- -- • - - -
0
Percentage of member ownership 70 0
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if single):
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if single):
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
•
Is the applying Limited Liability Company controlled by anothercorporation/company?
OYES ONO
If yes,provide the following:
1) Name of corporation
2) Supply an organizational chart of the controlling corporation named above
3) Controlling corporation MUST be registered with the Nebraska Secretary of State,copy of articles must
be submitted with application§53-126
•
Indicate the company's tax year with the IRS(Example January through December)
StartingDate:January 1 EndingDate:December 31
Ls this a Non Profit Corporation?
OYES ONO
If yes;provide the Federal ID #.
Ii
kf
In compliance with the ADA,this corporation insert form 3a is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
10/26/2018 Nebraska Secretary of State-Corporation and Business Entity Searches
Nebraska Secretary of State
0 Corporate, UCC and EFS filings and document images may be unavailable online for filing,viewing and purchase due to
system maintenance beginning Monday,October 29th at 6:00 P.M.through 8:00 P.M.We apologize for any inconvenience this
may cause.Thank you for your patience during this time.
FARNAM LODGING, L.L.C.
Fri Oct 26 17:29:22 2018
•
SOS Account Number
10233688
Status
Active
Principal Office Address
222 S 15TH ST SUITE 401N
OMAHA, NE 68102
Registered Agent and Office Address
DARRELL K.STOCK
SUITE 203
5533 S.27TH ST.
LINCOLN, NE 68512
Designated Office Address
222 S. 15TH ST.,SUITE 401N
OMAHA, 68102
Nature of Business
Not Available
Entity Type •
Domestic LLC
Qualifying State:NE
Date Filed
Nov 03 2016
Filed Documents
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button.Your Nebraska.gov account will be charged the indicated amount for each item you view. If no Purchase Now button appears,
please contact Secretary of State's office to request document(s).
•
Code . Document Date Filed Price
CRTO Certificate of Organization Nov 03 2016 $0.45= 1 page(s)@$0.45 per Purchase Now
page •
_ _ ...... .
BR Biennial Report Mar 10 2017 $0.45= 1 page(s)@$0.45 per Purchase Now •
page
•
PP Proof of Publication Aug 02 2017 $0.45= 1 page(s)@$0.45 per Purchase Now
•
page . .. •
•
Good Standing Documents
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httpsl/www.nebraska.gov/sos/ccorp/corpsearch.cgi?acct-number=10233688
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Apostilled or Authenticated.
Online Certificate of Good Standing with Electronic Validation
$6.50
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httpsl/www.nebraska.gov/sos/ccorp/corpsearch.cgi?acct-number=10233888 2/2
NE Sec of State John A.Gale CORP-CRTO
9000226381-Page 1 of 1
FARNAM LODGING,L.L.C:
Filed:11/03/2016 03:06:25 PM ,
•
CERTIFICATE OF ORGANIZATION :
OF :
FARNAM LODGING,L.L.C.
•
The undersigned, acting as Organizer of a Limited Liability Company formed under the • j
Nebraska Uniform Limited Liability Company Act, does hereby submit this document for filing
with the Secretary of State and hereby verifies:
1. Name. The name of the company shall be Famam Lodging,L.L.C. •
•
2. Purpose. The company is organized to engage in and to do any lawful act
concerning any and all lawful business, other than banking or insurance, for which a limited
liability company may be organized under the laws of Nebraska. The company is not organized to
•
provide a professional service
3. Designated Office. The address of the designated office of the company in
Nebraska is:
222 S. 15th St., Ste 401N,Omaha,NE 68102
4. Registered Agent. The name and address of the company's registered agent in
Nebraska is:
Darrell K. Stock 5533 S.27a'St., Suite 203,Lincoln,NE 68512
5. Effective Date. The effective date shall be the date of filing.
6. Duration. The period of duration of the company shall be perpetual.
EXECUTED by the undersigned Organizer on the 2nd day of November,2016.
Darrell K.Stoc , rg ' er
5533 S.27th St.,Suite 203
Lincoln,NE 68512
. (402)474-8690
.
1
FARNAM LODGING, L.L.C.
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
2431 FARNAM ST.
OMAHA,NE 68102
BUSINESS PLAN:
Famam Lodging, L.L.C. intends to operate a Holiday Inn Express & Suites in Omaha,Nebraska.
As a part of the business, there will be a market that sells liquor off sale and social activity/event
areas which will have alcoholic beverages available to our customers.
•
•
{
•
•
•
111111111111111111
a�IIII�IIIItIIIyII1�'pIIInIIIIaIgp�I1IIryryIIIIIII�1��I'��II�IIIpIIIIIIryN��'InryeIIIryIII�III��IAI�I {I{CIIIIy��I�t'II��ry��III�'fNI��III IIIIAIIIBp NI�NyIIInI��II1III'H IVI �II�IInIIIIIIXI'I� �ryNI �( r� '} `tuYtdt �`f 1 K� \tl'SE� 1tt .IIIIIIIIIIIIIIIIIIIIIII0111111�9N111411N1 III �IIIIIIAIII�ll llllllllll II l•S ' I l
YI
DEED E01711 •
i
ff1N� T 1N I1I�N IIII I11111 INN 111111 I
MAY E5 2017 10:E5 P 1
Received-DIANE L.BATTIATO
Register a Deeds,Douglas county.NE
I 'I8I5lI/pa2l5pyE201777��11'p0::2IS:4'�6..,�57 tNy1�®I
Of1YWW®Illtll®I1HIIIYIYI
2017039830
77ze above.spare it nesen rd for sue by Ih e R egiseer of Deeds
Return To: Darrell K.Stock,Attorney at Law,5533 S.27^St,Suite 203,Lincoln,NE 68512(402)474-8690
QUITCLAIM DEED
Deepak M. Gangahar, a married person, and Kirti K. Trivedi, a married person, Grantor,
whether one or more, in consideration of One Dollar ($1.00) and other good and valuable
consideration, receipt of which is hereby acknowledged, quitclaims and conveys to Farnam
Lodging,L.L.C., Grantee, the following described real estate(as defined in Neb.Rev. Stat. § 76-
• 201)in Douglas County,Nebraska:
Parcel 1: Lot Two(2),Kellogg Place Replat 1,City of Omaha,Douglas County,Nebraska
Parcel 2: The East One Hundred Ninety(190)feet of Sublot One(1)of Lots Five(5)and Six(6)and - r`
the East Fifty-Four(54)feet of the North Ten(10)feet of Sublot Eight(8)of Lot Six(6),
and the East Fourteen(14)feet of Sublot Ten(10)of Lot Six(6)in Capitol Addition,an
Addition to the City of Omaha,Douglas County,Nebraska. l
•
Executed: Met )cr Lana
iii
v i Dee•
" 3
STATE OF NEBRASKA )
)ss.
COUNTY OF nbi tam
: r
The foregoing instrument was acknowledged before me on ffl(X. 1 t t , 2017
by Deepak M.Gangahar,a married person,and Kirti K Trivedi,a married person,Grantor.
/YY1, .771 r /Y l G
Notary Public
GEte AN NOTMT•StalaotNebrasti -i
DREA HOLMSTEDT
!Agen t tt�Number 1Z 2020I
MANAGER APPLICATION office Use �+ ��C�'"y,
INSERT-FORM3c RECE I�
;NEBRASKA LIQUOR CONTROL COMMISSION O�j c, u ( _
-- -----301 CENTENNIAL-MALL-SOUTH---- ----- - - -
POSOLN,NE _. NEBRF.SkA LK1U°" 4,
LINCOLN•NE 68509-5046 , �W`.
PHONE:(402)471-2571 f , jM[S:.,K`h
FAX:(402)471-2814 CANT R J►-
' Website:www.lcc.nebraslca.gov
MUST BE:
✓ Include copy of US birth certificate,naturalization paper or current US Dassuort
V Nebraska resident. Include copy of voter registration card or print out document from Secretary of
State website
✓ Fingerprinted. See form 147 for further information,read form carefully to avoid delays in
processing,this form MUST be included with your application
V 21 years of age or older
•
Name of Corporation/LLC: Famam Lodging,L.L.C.
Liquor License Number:
Class Typ a (if new application leave blank) .
Premise Trade Name/DBA: Holiday Jim Express Downtown Omaha
Premise Street Address: 2431 Famam St.
City: Omaha County:Douglas Zip Code: 68102
Premise Phone Number: No number at this time
Premise Email address: andrea.holmstedt@anantops.com [Andrea Holmstedt]
The individual whose name 'e Ii ted as a corporate officer or managing member as reported on insert
form 3a or 3b or list-• • ith t, • ommission. To see authorized officers or members search your license
information her
f ak .Lttirri 855317'art: i7 I00 0vi e= 171 ..., s _r°V F
itS
dr
(Faxed . gnatures are acceptable) ,,
•
1
Farm 103 t
Rcv July 20111
Paget of k
Manager's information must be completed below PLEASE PRINT CLEARLY''`
Last Name: Holmstedt First Name: Andrea R.
MI:
Home Address: 8015 N. 28th St.
City: Omaha County: Douglas Zip Code: 68112
Home Phone Number: (402) 991-0644
Driver's License Number&State: NE
Social Security Number:
Date Of Birth: Place Of Birth: Omaha,NE
Email address: andrea.holmstedt@anantops.com
Ate you :ali ed?If yes, complefe spouse's"tnformation(Esie If a sp:MAO aff davii`has beenatibmttted)
1YES ❑NO
`Spouse.'syinfomiatign a::. s ,y'1'
Spouses Last Name: Holmstedt First Name: Noel MI: J.
Social Security Number:
Driver's License Number&State: NE --- -
Date Of Birth:_ • Place Of Birth: Omaha,NE
•r
APPLICANT&SPOUSE MUST LIST F$PENCE(8)FOI2 HE PAST TEN'(10)' 045
APPLICANT
CITY& STATE FJ20M AR YEAR
CITY& STATE FYEROM AR
Omaha,NE 1976 Present .Omaha,NE 1975 Present
Form 103
Rev July 2018
MANAGERS LAST TWO-EMPLOYERS
YEAR TELEPHONE
FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR NUMBER
2001 2012 Holiday Inn Lisa Schnackel 402-393-3950
2012 Present Anant Operations. Inc. Kirti K. Trivedi 402-933-6959
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, EVER been convicted of or plead guilty to any charge.
Charge means any 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.
{1 YES ❑ NO
If yes,please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mm/yyyy) (City&State) Charge
See Attached
•
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
OYES ONO
IF YES, list the name of the premise(s):
QrP attarherl
3. Do you, as a manager, qualify under Nebraska Liquor Control Act( 53-131.01)and do you intend to
supervise, in person,the management of the business?
OYES ONO
Form 103
Rev July 2018
FARNAM LODGING,L.L.C.
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
• 2431 FARNAM ST. •
OMAHA,NE 68102 •
• ATTACHMENT TO MANAGER APPLICATION FOR LIQUOR LICENSE RESPONSE TO QUESTION 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,EVER been convicted of or plead guilty to any charge.
. Charge means any 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.
See attached Court Case Summaries
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mm/yyyy) (City&State) Charge
Andrea R.Helmstedt 7/26/2012 Omaha,NE Speeding Guilty Plea by Waiver
PI..M NM,'The feaa and pant charge*
were In the name of Andrea ItKress, 7/7/2004 Omaha, NE Speeding Guilty Plea by Waiver
applicants maiden nnme
1/12/2005 Omaha,NE Speeding Guilty Plea by Waiver
official Nebraska Government Website
Nebraska Judicial Branch
Case Summary
In the County Court of Keith County
"The Case ID is TR 12 0000821
citation No. : EE 1900602
State v. Andrea R Holmstedt
The Honorable Edward Steenburg, presiding.
Classification: Statute
Filed on 07/26/2012 by the county Prosecutor
This case is Closed as of 07/26/2012
It was disposed as Guilty Plea by waiver
Original appearance date 08/06/2012 at 09:00
Abstract of Judgment sent to Department of Motor vehicles
Parties/Attorneys to the Case
Party Attorney
Plaintiff ACTIVE
state of Nebraska Randy C Fair
121 West 3rd Street
P.O. Box 29
Ogallala NE 69153
• 308-284-2091
Defendant ACTIVE
Andrea R Holmstedt
8015 N 25th Ave
Omaha NF 68112
Date of Birth is ; Drivers License is NE
Offense Information
count Charge offense class 01 speeding 6-10 MPH county/State ; Infraction
offense Date is 07/14/2012
Plea is Guilty/Admit
Finding is Guilty
sentence includes:
State Fine of $25.00
Arresting Officers
Agency officer
Nebraska state patrol Kevin Horst
Cdurt Costs Information
Incurred By Account Date Amount
Defendant Filing Fees 07/26/2012 $18.00:
Defendant NSC Education Fee 07/26/2012 $1.00
Defendant Dispute Resolution Fee 07/26/2012 $0.75:
Defendant Indigent Defense Fee 07/26/2012 $3.00
Defendant uniform Data Analysis Fee 07/26/2012 $1.00
'Defendant J.R.F. 07/26/2012 $6.00
Defendant Filing Fee/JRF 07/26/2012 $2.00;
official Nebraska Government website
Nebraska Judicial Branch
case Summary
In the County Court of Harlan County
The Case ID is TR 04 0000257
citation No. : PA 0552306
State v. Andrea R Kress
'classification: Statute
Filed on 06/24/2004 by the County Prosecutor
This case is closed as of 07/07/2004 '
It was disposed as Guilty Plea by waiver
original appearance date 07/15/2004 at 09:30 '
'Abstract of Judgment sent to Department of Motor Vehicles
Parties/Attorneys to the case d
8
li
Party Attorney
Plaintiff ACTIVE
state of Nebraska Bryan S McQuay y
707 west First St. • P
P.O. Box 755 +.
Alma NE 68920
. 308-928-2189 11
Defendant ACTIVE
Andrea R Kress '
3058 5. 60 #5 j
Omaha Mr 68106
Date of Birth is Drivers License is NE
offense Information
count charge offense class
01 Speeding 21+ MPH County/State ; Infraction
offense Date is 06/19/2004
Plea is Guilty/Admit
Finding is Guilty
sentence includes: t
state Fine of $200.00
Arresting Officers
Agency Officer ,
Nebraska state Patrol B Buxbaum .
Court costs information
Incurred By Account Date Amount
Defendant Filing Fees 06/24/2004 $18.00'
Defendant NSc Education Fee 06/24/2004 $1.00:
Defendant Dispute Resolution Fee - 06/24/2004 - $0.75
Defendant Indigent Defense Fee 06/24/2004 $2.75 •
Defendant Uniform Data Analysis Fee 06/24/2004 $1.00;
1.
Defendant J.R.F. ' 06/24/2004 $5.00
Defendant L.E.I.F. 06/24/2004 $2.00- i
Defendant L.A.S.F. 06/24/2004 $5.00
b
l'
Official Nebraska Government Website
Nebraska Judicial Branch
Case summary
In the County court of Douglas County
The Case ID is TR 05 0000587
'Citation No. : DC 1202020
State v. Andrea R Kress
Classification: statute
• .Filed on 01/06/2005 by city Prosecutor of omaha
This case is closed as of 01/12/2005
It was disposed as Guilty Plea by Waiver
original appearance date 01/26/2005 at 09:00
Abstract of Judgment sent to Department of Motor Vehicles
Parties/Attorneys to the case
Party Attorney
Plaintiff ACTIVE
State of Nebraska Martin J Conboy 1701 Farnam Street
Omaha NE 68183
402-444-5290
Defendant ACTIVE
Andrea R Kress
3058 S 60 st, apt.#5
omaha NE 68106
Date of Birth is i Drivers License is NE
offense Information
count charge offense class
01 Speeding 11-15 MPH County/State ; Infraction
offense Date is 12/22/2004
Plea is Guilty/Admit
Finding is Guilty
sentence includes:
State Fine of $75.00
Arresting officers
Agency officer
Omaha Police Department Steven Lozano '•
court costs Information
Incurred By Account Date, Amount
Defendant Filing Fees 01/06/2005 $18.00
.Defendant NSC Education Fee 01/06/2005 $1.00'
•
Defendant Dispute Resolution Fee 01/06/2005 $0.75
Defendant Indigent Defense Fee 01/06/2005 $2.75!
Defendant uniform Data Analysis Fee 01/06/2005 $1.00
Defendant J.R.F. 01/06/2005 $5.00;
Defendant L.E.I.F. 01/06/2005 $2.00i
Defendant Legal Aid/services Fund 01/06/2005 $5.00:
FARNAM LODGING,L.L.C.
HOLIDAY INN EXPRESS DOWNTOWN OMAHA
2431 FARNAM ST.
OMAHA, NE 68102
ATTACHMENT TO MANAGER APPLICATION FOR LIQUOR LICENSE RESPONSE TO
QUESTION 2:
Have you or your spouse ever been approved or made application for a liquor license in
Nebraska or any other state?
Name of Premises:
1. Husker Management, Inc. d/b/a Holiday Inn Express & Suites Lincoln Southeast
2. DMK Union General Partnership d/b/a Holiday Inn Downtown Omaha
3. Tamarin Lodging, LLC d/b/a Holiday Inn Lincoln Southwest
4. LNK Lodging, LLC d/b/a Holiday Inn Express& Suites Lincoln Airport
5. 24th Street Enterprises,LLC d/b/a Even Hotel Downtown Omaha
6. LNK2 Lodging, LLC d/b/a Fairfield Inn& Suites—Lincoln Airport
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NLCC Training Certificate Issued: 4/20/2017 Name on Certificate: Andrea R. Holmstedt
•
•
Applicant Name (nril tyy) Name of program(attach copy of course completion
certificate)
Andrea R. Holmstedt 4/70/17 Responsible Beverage Service Training
•
*For list of NLCC Certified Training Programs see training
• k
Experience_
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
Andrea Holmstedt 2N1-2n 12 Holiday Inn,Omaha,NE;Banquets&Bartender duties
included Accounts Payable/Receivables(order alcohol and pay k
for it);monthly inventory,hotel,banquets and waterpark
2001-2012 Holiday Inn,Omaha,NE;Accounting
Anant Operations,Omaha,NE;Corporate Controller duties
2012-Present ineludc Accounts Payable/Receivables,order and pay for
alcohol;monitor daily alcohol inventory and compare to POS
system receipts;document alcohol inventory and coach,council
and provide training for various hotels
2017-Present Liquor license manager for serveral hotels see
attached list In response to question#z
5. Have you enclosed form 147 regarding fingerprints?
EYES fINO
•
Form 103 F
Rev July 2018
*RBST Online
Training Credentials �y `� ��y �+y ��'{ ry RI,-
� +� +�
�i✓��✓�1✓ /�ri.:.�`J_�.J a/.J1�✓_✓J✓J i_.J✓.✓J, ...- ._/'.�✓✓'.....L/_:!J�l.:l�d..✓_-_-`...- _.1J r�.
4, a i... in
'%l ANDREA R HOLMSTEDT „,\
nC.. 1
6
,', has earned a
Certificate of Achievement ":
i'` fit` -for those who serve or sell alcohol in Nebraska
' ;
fcs it # RB-0078833 'to,'
�
�' F y
S Expires: 04-20-2020 Amount Paid: $ .1 0
( I l`i
�'fil Responsible Beverage Service Training 'str Yil
L ; NEBR ASK A c
4,
1
2
- . ., .3it RBST Online
Training Credentials
General Credential Number Earned Expires
Andrea R Holmstedt RBST GENERAL RB-0078833 0420-201T 04-2Q-2020
8015 n 28 ave
Omaha NE 68112 .
•c.trfcrti.;
. ,... titll, 1
i-... -c. 4 r
i I,4 ,....4 t N e DrasKa Vri.:$ .f. ., :.54;. !: 1,.,,,„
. ,
2/2
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 l:
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 :,t
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 a uracy of the information
contained in FBI identification record. The procedures for obtainin a c •rr• tit , . up•sting an
FBI identification record are set forth in Title 28, CFR, 16.34.
Signature of Manager Applicant S ature of Spouse tt
ACKNOWLEDGEMENT
State of Nebraska •
County of L oun t.a The foregoing instrument was acknowledged before
methis
• S a D 1 r by Prap2Rr i
hU +4 9- nag/ X fir/m
date NAME OF PERSON : -CtiNOWLEDGED
state ott4ebrado-nonelai Notary
n� • a sear My Cmmisaa020
Notary Public signaturemo
5'
In compliance with the ADA,this application is available in other formats for persons with disabilities. F
A ten day advance period is required in writing to produce the alternate format.
Farm 103
Rev July 2018
Page 6 of 6
•
SPOUSAL AFFIDAVIT OF ofaceuec RECEIVED
NON PARTICIPATION INSERT
30BCENTE LIQUOR
CONTROL
SOUT COMMISSION OCT 2 U 2018
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 NEBRASKA LIQUOR
FAX:(402)471-2814
Website: www.lcc.nebnstra.gcv CONTROL COMMISSION
•
X 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.
X 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. If, it is
determined that my spouse has violated(§53-125(13))the commission may cancel or revoke the liquor license.
1rYail _eb
ature of NO -PARTICIPATING SPOUSE Signature of APPLICANT
Noel J.Holmstcdt Andrea R.Hbhnstedt
Print Name // •
Print Name !-
•
• State of Nebraska,County of C&n CCe 5 r State of Nebraska,County of lft✓1 C.4 5 712(`
The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me
this f t i1 &I Y (date) this
/Siatievv L //1 d'Q/3(date)
by 04 1 FL! SIQ� by l�l 4 r00.. ✓YI S�Q�(�'
I 1 Name of person acknowledged Name of person acknowledged
ndividual signing document) - (Individual signing document)
�LJ
Notaryc24z.g24<7.2.,/___ •
lic tur Notary Public •� Stabonlebratka-Genstal Natal,
BRElinnbutACKa
" BRENaincit I J111105s2020
MY g020 Adz Sul
In compliance with the ADA,this spousal affidavit of non participation is available In other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 116
REV NOV 2016
Page 11
PRIVACY ACT STATEMENT/ }41#OFeltseoaly
SUBMISSION OF FINGERPRINTS/ •
PAYMENT OF FEES TO NSP-CID RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH OCT 2 1=20T8`
PO BOX 95046 t ateStamp HERE ONL =LINCOLN,NE 68509-5046
PHONE: (402)471-2571 �
FAX:(402)471-2814 ONTROi.
Website:www.lcc.nebraska.gov
THIS FORM IS REOUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED:
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REOUIRED 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
3800 NW 12th Street
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 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.
Trade Name: Holiday Inn Express Downtown Omaha
Name of Person Bring Fingerprinted: Andrea Holmstedt
Date of Birth: _ Last 4 SSN: Date fingerprints were taken: 4/21/2017
Location where fingerprints were taken:NSP Troop A Headquarters,Omaha.NE
Hgw was payment made to NSP?
@ 4SP PAYPORT. ❑CASH 0 CHECK SENT TO NSP CK#
My fingerprints are already on file with the commission—fingerprints completed for a previous
application less than 2 years ago? YES ®
SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED
FORM 147
REV MAY 2018
NEBR,r SICA:GQV
PURCHASE RECEIPT
Nebraska State Patrol-Criminal Identification Division
3800 NW 12th Street Suite A
lincoln NE 68511
(402)479-4971
miranda.erick@nebraslca.gov
OTC Local Ref 1D: 28583058
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE
Status: APPROVED
Customer Name: Andrea Holmstedt
Type: Visa
Credit Card Number: **** ******** Rp
Total Amount Charged USD$46,38
Items Location Quantity TPE Order Total
ID Amount
Liquor License 1 31282244 $45.25
Applicant Name: Andrea Holmstedt
Date of Birth:
Last four of Social Security Number t
Total remitted to the Nebraska State Patrol-Criminal $45.25
Identification Division
4
•
PRIVACY ACT STATEMENT/ � z
SUBMISSION OF FINGERPRINTS/
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION `} `
301 CENTENNIAL MALL SOUTH i ,$ i Q11C�R
PO BOX 95046 KIF:CC:4.0.SORSailMg,
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 �.'... ....
FAX: (402)471-2814
Website:www.lcc.nebraska.gov
THIS FORM IS REOUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: 1
is
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REOUIRED FEE TO TH$
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
3800NW 12Th Street
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 FBI identification record. The procedures for obtaining a change, correction,or updating a
FBI identification record are setforth in Title 28, CFR, 16.34.
•
Trade Name: Holiday Inn Express Downtown Omaha
Name of Person Bring Fingerprinted: Kirti K.Trivedi
Date of Birth: Last 4 SSN: Date fingerprints were taken:/O/021/ {{
Location where fingerprints were taken: NSPlicv Q l(y fie
How was payment made to NSP?
LISP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK#
My fingerprint • e already on file with the commission—fingerprints completed for a previous
application ss an 2 years ago? YES
SIG A I D OF P N BE FINGERPRINTED
FORM 147
REV MAY 2018
•
Page 1 of 1
Brenda Black
From: "ANDREA HOLMSTEDT"<ANDREA.IIOLMSTEDT([L�anantops.com>
Date: Monday,September 10,2018 12:08 PM
To: "Brenda Black"<bblack@inebraska.com>
Subject: Fw:nebraska-Recept-TRIVEDI
Andrea Helmstedt I Anant Operations Inc.' Corporate Controller
Mailing Address I PO Box 3847 I Omaha,NE 68103-0847
Office:402.933.6959 opt.2 l Fax:402.614.186'7 I Email:andrea.holmstedt@anantops.com
From:nebraska<NoReplyOTC@egov.com>
Sent: Monday,September 10,2018 12:07 PM
To:ANDREA HOLMSTEDT •
Subject:nebraska-Receipt
PURCHASE RECEIPT
Nebraska State Patrol-Criminal Identification Dlvhbn
3800 NW 12th Street,Suite A
Uncoh NE 68521
14021479'4971
minhde.erlckOnebraska.gov
OTC Local Ref ID:2867751E
THANK YOU FOR USING THE NEBRASKA STATE PATROL RAYPORT SERVICE
Status: APPROVED
Customer Name: Andrea Helmstedt
Type: Visa
Credit Card Number: " see'
Total Amount Charged USD$46.38
Items location Quantity TPE Order ID Total Amount
liquor License 1 31315576 $45.25
Applicant Name:KBm TRIVEDI
Date of Binh:r
te:.kc:sr:.auat.egb L,.Numbe.
Total remitted to the Nebraska State Patrol-Criminal Identification DWnion $4525
9/10/2018
PRIVACY ACT STATEMENT/ � 4ht U
SUBMISSION OF FINGERPRINTS/ k=
PAYMENT OF FEES TO NSP-CID _
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH : '' w NV RA l jot ,Oj
PO BOX 95046 s ita [z . ,
LINCOLN,NE 68509-5046 r
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.nebraska.gov t
THIS FORM IS REOUIRED TO 13E 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/eo/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
3800 NW 12th Street
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: Yourfingerprints 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 a
FBI identification record are set forth in Title 28, CFR, 16.34.
Trade Name: Holiday Inn Express Downtown Omaha
Name of Person Bring Fingerprinted: Deepak M.Gangahar /
Date of Birth: _.__. __ _ _ Last 4 SSN _ Date fingerprints were taken: 9/I7//i
Location where fingerprints were taken: rl S la o reC.Q.@ log t L d b aA atL. t'
How was payment made to NSP?
21NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK it
My fingerprints are already on file with the commission—fingerprints completed for a previous
applic i n less than 2 years ago? YES ❑
SIGN TURE REQUIRED OF PERSON BEING FINGERPRINTED
FORM 147 .
REV MAY 2018
Page l of 1
Brenda Black
From: "ANDREA HOLMSTEDT"<ANDREA.HOLMSTEDT@anantops.com>
Date: Monday,September 10,2018 12:08 PM
To: "Brenda Black"<bblack@inebraska.com>
Subject: Fw:nebraska-Receipt-GANGAHAR'
•
•
Andrea Holmstedt I Anent Operations Inc.I Corporate Controller
Mailing Address I PO Box 3847 I Omaha,NE 68103-0847
Office:402.933.6959 opt.2 I Fax:402.614.1867 I Email:andrea.holmstedt@anantops.com
From:nebraska<NoReplyOTC@egov.com>
Sent:Monday,September 10,201812:05 PM
To:ANDREA HOLMSTEDT
Subject: nebraska-Receipt
PURCHASE RECEIPT
Nebraska State Patrol-Criminal Identification Division
3800 NW 12th Street,Suite A
Uncotn NE 68521
14021479-4971
min nda.erick@nebrasb.gov
OTC Local Ref ID:28678050 •
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE
Status: APPROVED
Customer Name: ANDREA HOLMSTEDT
Type: VIsa
Credit Card Number: •••••••••••
Total Amount Charged USD546.38
Items Location Quantity TPE Order ID Total Amount
Liquor license 1 31325536 $45.25
Applicant Name:DEEPAK GANGAHAR
Date of Birth:
Last four of Social Security Number
' Total remitted to the Nebraska State Patrol-Criminal Identification Division $45.25
9/10/2018
NOU-19-2018 10:55 From:ranant Operations 4026141867 To:4024445263 Page:3/3
CITY OF OMAHA
STATEMENT OF BUSINESS ACTIVITY
For
RETAIL LIQUOR LICENSE APPLICANTS
In accordance with Omaha City Municipal Code, Section §15-22, a statement of business
activity must be submitted to the Omaha City Council by all applicants for retail liquor licenses.
This written statement shall describe all types of business or activity that will be operated on the
premises in conjunction with the proposed license. A failure to include a business or activity will
be considered by the City Council as the applicant's representation that the omitted business or
activity will not occur on the licensed premises without City Council approval. Failure to operate
consistent with this statement may be grounds for cancellation, revocation, suspension, or non-
renewal of the license (OMC §15-42).
DESCRIBE ALL BUSINESS OR OTHER ACTIVITIES THAT WILL OCCUR ON THE
LICENSED PREMISES.
Ren4Ci 1 r f hr4r ( morn nw mtr4*j SfnrP
I have read and understand the Good Neighbor Ordinance (Omaha Municipal Code
Section-i §18-90 to §18-92.)
FOX it L,ut° r ►�.C.
Corporation and/or Trad a /DBA (Please Print)
4r1@,wP 0. ►-krnsthA+- CAN v-i4 i I P P"
Name &Title of Applicant or Authorized Representative
RECEIVED 11-19-' 18 11 :03 FROM- 4026141867 TO- Omaha City Clerk P0003/0003
PUBLIC WORKS DEPARTMENT REPORT ,;b.<) j
_
DATE: NOVEMBER 8,2018 DUE DATE: NOVEMBER 20,2018 '>�. '�
CITY COUNCIL HEARING DECEMBER 4, 2018
APPLICANT: FARNAM LODGING, L.L.C.,DBA "HOLIDAY INN EXPRESS DOWNTOWN
OMAHA"
LOCATION: 2431 FARNAM STREET
REQUESTED LICENSE OR ACTION: CLASS"C"LIQUOR LICENSE
DESIGNATION OF ADJACENT STREET (LOCAL,COLLECTOR,MINOR OR MAJOR
ARTERIAL EXPRESSWAY): /Y) I rite)r Pre r r rz_4
STREET WIDTH AND PROFILE: 1.5 ) Un.e • ct_.12 ..�.7l Dn...c! W� ]
SPEED LIMIT: ;DC) PYI.Ph J
AVERAGE DAILY TRAFFIC AND PEDESTRIAN FLOW: /(/ no Veht/ J
V2� Pecisitid
ACCIDENT REPORT AT ADJACENT INTERSECTION:..,g4'h IL!)/J-C c'- Far/ A Ia\Stet'ex)--.19
(a//oil11-& ia/.31/tt-) L cc�cl�rt�ls, ,�1-h 'k' ',@OS c•h - QrctrarV'S -
aLmin ,ent is d- 1..1a✓nor' St-,' -is - -/n(et lt.epvis , ea-/s-
I Q cc, • J9 rna rN w A5t41 AJrnla e. - r3 61Ctv ds-1 f5; ,
POTENTIAL TRAFFIC AND PARKING PROBLEMS: � YyW
/1-/
(Authorizfa Signature) (Date)
PLANNING DEPARTMENT REPORT
DATE: NOVEMBER 8, 2018 DUE DATE: NOVEMBER 20, 2018
CITY COUNCIL HEARING DECEMBER 4,2018
LOCATION: 2431FARNAM STREET
APPLICANT: FARNAM LODGING,L.L.C., DBA "HOLIDAY INN EXPRESS DOWNTOWN
OMAHA"
REQUESTED LICENSE OR ACTION CLASS "C" LIQUOR LICENSE
NEW LOCATION(X)NEW OWNERSHIP ( ) TYPE OF FACILITY: HOTEL
THIS REQUEST DOES 0 DOES NOT(X) PERTAIN TO AN OUTSIDE AREA(S)
IF SIDEWALK CAFE: R-O-W-LEASE PERMITS OBTAINED
IF OUTSIDE: OUTSIDE AREA IS FEET FROM THE NEAREST RESIDENCE
THIS PROPERTY IS ( X ) IS NOT ( ) WITHIN OMAHA'S CORPORATE LIMITS
(If not,do not proceed-Notify the City Clerk's Office and return this form)
********************************************************************************************************
ANNEXATION DATE: ORDINANCE NO. (Only if within last 24 months)
EXISTING ZONING: CBD-ACI-1(PL) EXITING LAND USE: NEW ESTABLISHMENT
ADJACENT LAND USE AND ZONING:
NORTH: - COMMERCIAL CBD-ACI-I(PL)
SOUTH: RESIDENTIAL DS-ACI-1(PL)
EAST: MIXED USE CBD-ACI-1(PL)
WEST: COMMERCIAL CBD-ACI-1(PL)
PARKING STALLS PROVIDED: 40+
EXISTING USE DOES(X) DOES NOT( )COMPLY WITH ZONING REGULATIONS
PLUMBING FIXTURES PROVIDED: WOMEN'S 3 TOILET STALLS(1 H/C)
MEN'S 1 URINAL+I H/C TOILET STALL
DATE SUBJECT PROPERTY WAS POSTED: November 16.2018
(Rule#7) DISTANCE OF PROPOSED LICENSE TO ANY SCHOOL,CHURCH,OR CITY PARK: OK
DISTANCE OF PROPOSED LICENSE TO ANY EXISTING LICENSE: OK
(State Law) DISTANCE OF PROPOSED LICENSE TO ANY CHURCH OK
SCHOOL OK HOSPITAL OK HOME FOR THE AGED,INDIGENT
/OR VETERANS OK,' COLLEGE OR UNIVERSITY OK
( ��ure) ///6//f
(Authorized ignature) (Date)
City of Omaha, Nebraska 17,
F mmidt,
U
t°
1819 Farnam — Suite LC 1 r e
Omaha, Nebraska 68183-0112 nVr `ria �e► ^
o a •x
Elizabeth Butler (402) 444-5550 'Co N-
C ity Clerk FAX (402) 444-5263 oR 4�
*kb FEI303
November 16, 2018
Farnam Lodging, L.L.C. Application for a Class "C" Liquor License
Dba"Holiday Inn Express Midtown Omaha"
2431 Farnam Street
Omaha,NE 68102
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application for
liquor license has been set for December 4, 2018 . 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 or his/her
representative 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.
Sincerely yours,
Elizabeth Butler
City Clerk
EB:clj
oMAH^• N
City of Omaha, .Nebraska � zi
t
1819 Farnam —Suite LC 1 man //orit c ki.1�`
n 'a dr" n
Omaha, Nebraska 68183-0112 . C
Elizabeth Butler (402) 444-5550 ti•
City Clerk FAX (402) 444-5263 °4.,./ 4-
FES �P¢
R November 16, 2018
Farnam Lodging, L.L.C. Application for a Class "C" Liquor License
Attn: Kirti K. Trivedi for Farnam Lodging, L.L.C., dba"Holiday
P. O. Box 3847 Inn Express Midtown Omaha", 2431 Farnam
Omaha,NE 68103-0847 Street
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application for
liquor license has been set for December 4, 2018 . 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 or his/her
representative 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.
Ordinance No. 37046, passed June 27, 2005, requires each applicant to submit a written
statement describing all types of business or activities that will be operated on the premises in
conjunction with the proposed license. Attached is the MANDATORY statement that must
be signed and returned (hand deliver, mail or fax) to the City Clerk's Office 7 days in
advance of the public hearing.
Sincerely yours,
Elizabeth Butler
City Clerk
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City of Omaha, Nebraskarv/�stafir ,N
1819 Farnam —Suite LC 1 01�
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Omaha, Nebraska 68183-0112 �� ;t:�ll ►
Elizabeth Butler z "v
(402) 444-5550 ?A '
City Clerk FAX (402) 444-5263 O�9T0 FEBRP4ry
November 16, 2018
Darrell K. Stock, Attorney Application for a Class "C" Liquor License
Darrell K. Stock, P.C., L.L.O. for Farnam Lodging, L.L.C., dba "Holiday
5533 South 27th Street, Suite 203 Inn Express Midtown Omaha", 2431 Farnam
Lincoln, NE 68512 Street, Omaha,NE
Dear Liquor License Applicant's Attorney:
This letter is notification that a hearing before the Omaha City Council on your application
for liquor license has been set for December 4, 2018 . 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 or
his/her representative 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.
Ordinance No. 37046, passed June 27, 2005, requires each applicant to submit a written
statement describing all types of business or activities that will be operated on the premises in
conjunction with the proposed license. Attached is the MANDATORY statement that must
be signed and returned (hand deliver, mail or fax) to the City Clerk's Office 7 days in
advance of the public hearing.
Sincerely yours,
Elizabeth Butler
City Clerk
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City of Omaha Nebraska oMAHA. N
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1819 Farnam —Suite LC 1 z W Ge i 'i'1
Omaha, Nebraska 68183-0112 0 �i;�1 �i ; ,N o
Elizabeth Butler (402) 444-5550 ,o - no.
City Clerk FAX (402) 444-5263 OFD FEBRVP¢�
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NOVEMBER 20, 2018 M fI C
NOTICE OF REQUEST: To consider a CLASS "C" LIQUOR LICENSE
APPLICATION which allows the sale of beer, wine and distilled spirits, by the drink
on the premises and package in the original 'package for consumption off
premises
APPLICANT: FARNAM LODGING, L.L.C.
DBA HOLIDAY INN EXPRESS MIDTOWN OMAHA
LOCATION: 2431 FARNAM STREET
As an owner of property within 500 feet of the above referenced location, you are
being notified that the Omaha City Council will hold a meeting and public hearing
on this request on Tuesday, DECEMBER 4, 2018 in the Legislative Chambers —
Level LC of the Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha,
Nebraska. The meeting begins at 2:00 PM.
A notice of this meeting published in the Daily Record NOVEMBER 26, 2018 .
Anyone interested in the actions of the Omaha City. Council should be in
attendance. To obtain additional information or to submit written testimony, please
contact Carman Johnson at 402-444-5324 or carman.iohnson(c�cityofomaha.orq.
ALL REQUESTS FOR SIGN LANGUAGE INTERPRETERS (SIGNERS) WILL REQUIRE A
MINIMUM OF 48 HOURS ADVANCE NOTICE. IF ALTERNATIVE FORMATS ARE NEEDED,
ALL REQUESTS WILL REQUIRE A MINIMUM OF 72 HOURS ADVANCE NOTICE.
PLEASE NOTIFY ELIZABETH BUTLER, (402) 444-5557, IF ARRANGEMENTS NEED TO BE
MADE.
E-MAILED TO NLCC:
RECOMMENDATION OF THE NEBRASKA LIQUOR CONTROL COMMISSION
Date Mailed from Commission Office: October 26 2018 tb
I, Elizabeth Butler Clerk of The City of Omaha,A Municipal Corporation
(City,Village or County)
Nebraska,hereby report to the Nebraska Liquor Control Commission in accordance with Revised Statutes of Nebraska,
Chapter 53, Sec 134(7)the recommendation of said city,village or county,as the case may be relative to the application for
a license under the provisions of the Nebraska Liquor Control Act as applied for by:
Farnam Lodging LLC dba Holiday Inn Express Downtown Omaha
2431 Farnam Street, OMAHA Nebraska (DOUGLAS County)
NEW APPLICATION for Class C-122853
45 days — 12-10-2018
1. Notice of local hearing was published in a legal newspaper in or of general circulation in city,village or county,
one time not less than 7 nor more than 14 days before time of hearing.
Check one ' Yes X No
The Statutes require that such hearing shall be held not more than 45 days after the date of receipt of this notice
from the Commission.
2. Local hearing was held not more than 45 days after receipt of notice from the Nebraska Liquor Control Commission.
Check one Yes X No
3. Date of hearing of Governing Body: December 4,2018
4. Type or write the Motion as voted upon by the Governing Body. If additional Motions are made by the Governing
Body,then Use an additional page and follow same format.
MOTION TO GRANT
5. Motion was made by: Christopher Jerram Seconded by: Brinker Harding
6. Roll Call Vote: 7-0
7. Check one: The motion passed: X The motion failed:
8. If the motion is for recommendation of denial of the applicant,then list the reasons of the governing body upon
which the motion was made.
(Attach additional page if necessary)
SIGN HERE DATE )`J`l l8'
Clerk signa ure