RES 2018-1073 - Bagdad Lounge appoints William E German manager •
�ysE sT,�"`a,, E-MAILED TO NLCC — �l _a
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w" �-0 STATE OF NEBRASKA
• G<: .•- r *'a Pete Ricketts 7�7
w.,M,p'" . y;-:i
�a :s i 1\EBRASKA LIQUOR CONTROL.COMMISSION
.a`• Governor
`i o'S,ei A Hobert B. Rupe
i ' Executive Director
�,.ti�•�..... ... G� Jam:
'4.41,,Rcti r-yB rs 301 Centennial Mall South,S"Floor
• 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)
OCT
�a.r s 1.8 AM:a:40 web address http://www.lcc.nebraska.gov/
City 1
Clerk ME-FtL'l
October 16, 2018 .
To: • CITY CLERK OF Omaha •
Email: carman.johnson@cityofomaha.org
Manager Name: William E German
Licensee Name: Tangier Temple Holding Corp
Licensee Trade Name (DBA): Bagdad Lounge
License Number: 04320 tl Ctl�
Date Due: November ill 30, 020/k .
I have attached a copy of a new corporate manager application that was submitted to the Nebraska
Liquor Control Commission. Please complete the following information below to indicate your
recommendation. Send back to Kim Frederick at kim.fredericknebraska.gov or fax to (402) 471-
2814. If you have questions concerning this matter, please contact our office at (402) 471-2573.
X APPROVED •
NO LOCAL RECOMMENDATION
DENIED
COMME TS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES)
Li* ,
RP S / . 1 015 A)0 ite Pli he 1L-- 020 2.0 ieV
Y , d fZI [t
Clerk Signature: ) . . Date: II O
KMF
Janice M.Wiebusch Robert Batt Bruce Bailey
Commissioner . Chairman
Commissioner
An Equal Opportunity k:mploye.r
•
MANAGER APPLICATION Office Use
INSERT-FORM 3c RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH G C 0 1 2018
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 NEBRASKA LIQUO''
FAX:(402)471-2814 CONTROL COMMISS:a:
Website:www.lcc.nebraska.gov
MUST BE:
✓ Include copy of US birth certificate,naturalization paper or current US passport
✓ 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
✓ 21 years of age or older
Name of Corporation/LLC: 7'4N 2 f,Q rein OL F ao L))TA)C e o R P
Mire nt t[ .4',4.np .< ,' .n�. ,y 4 +14$.
Liquor License Number: D (/ 9,2 0 Class Type e (if new application leave blank)
Premise Trade Name/DBA: A fo D 4 P L o u N Co f
//Premise Street Address: a 8a 3 S g,-1- S (—
`City: D m Ally County: -Po uy /45 Zip Code: (o$-/, (/
`1 Premise Phone Number: Yo a- 3 9a- a v o Y
Premise Email address: 1-4,7)M 4' cLJ TA N c_f' s,'f Q_riv E.C ol17
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with the Commission. To see authorized officers or members search your license
infor•I ation her
:, d3 rr �, � a i en• ti- s r
5 .�1 T�C7Y3 : RE.T a `:0114 OF;NEOltil �..,.�._ .
(Faxed signatures are acceptable) .
Form 103
Rev July 2018
Page 2 of 6
\ate
Last Name: e r m ah First Name: f,) I f/i a el MI: E
Home Address: q g 44/ 5 9a 4 v
City: C,n a h GL County: 7o u 9/4 s Zip Code: to
et-
Herne Phone Number: yo 2-
Driver's License Number&State:
Social Security Number:
Date Of Birth: — Place Of Birth: - i'I /P/Ig , E
Email address: p(o( -I-4 ,T£e 5 14 R s,u f. (nor'
s r a �e� al fs'°` eo .� n e ab.. .yyr,3 tt#Jtc ro°r,r -
.. ��.+yyyp��� ;S �1� y7 �t ,yu ry
.:...� Q�.i ,...n ;: .�4rr`�,: Q .p, ). �k.,.,;: 'W= ° `.w..rw�.., � �'t?� k _��°°�Qtil Nrnq�,�5,. .eA
Xi YES ❑NO 4
reov /jam
Spouses Last Name: 66e_A A First Name: L 1711--6 MI:
Social Security Number:
Driver's License Number& State:
Date Of Birth: Place Of Birth: gWt.7r)-7 r
r i� '� k rt l • ° (�u,�Z�e°z J 1 y Y� a �. liar. �yi ^ Y ♦s t) s e t 5 k .:
,41 \ �b�• 4R P �4E%/lsi9 NU"� �Y �Ify} Y ig ���' ]F�l�� 6 L�.JF • ��,��:
sn r r ;� { E#ayy ! 5 ' i95i �L ram " jl� eF9 4 �*'
-... '-r�s. .�w�z.i�s�+t+t'•�,'-•�.4r."M' ''-�S��"..r.�.�._. .. �Tier���„++',A
CITY&STATE YEAR YEAR CITY& STATE YEAR YEAR
FROM TO FROM TO
aiii9a 7‘2- � /ql�I ,�0Ii L i - xlE /97.4 i /S3/
Form 103
Rev July 2018
Page 3 of 6
.a.'�ss. ..,a6- -k'ir'"'� �__ C�q. !;-. ..M_ v:is Asi)
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
O1J
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, Uftlt been convicted of or plead guilty to any charge.
Charge means my 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 vt'olatJ s 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 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
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
OYES NO
IF YES,list the name of the premise(s):
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?
tgYES ONO
Form 103
Rev July 2018
Page 4 of 6
4. List the alcohol related training and/or experience(when and where)of the person maki tion.
toNE
*NLCC Training Certificate Issued: Name on Certificate:
Applicant Name Date Name of program(attach copy of course completion
(`nm/yyyy) certificate)
*For list of NLCC Certified Training Programs see training
•
Experience:
Applicant Name/Job Title Date of Name&,Location of Business:
Employment:
•
5. Have you enclosed form 147 regarding fingerprints?
DYES O
•
Form 103
Rev July 2018
Page 5 of 6
v_ �,ik-'n 1 r �:t -n• �+7 ; i�`0 n3 .i*v G lei r p ��h a -•!¢ R if
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The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the
applicant and/or spouse of applicant who makes the above and foregoing application that said application has
been read and that the contents thereof and all statements contained therein are true. If any false statement is
made in any part of this application,the applicant(s)shall be deemed guilty of perjury and subject to penalties
provided by law. (Sec §53-131.01)Nebraska Liquor Control Act.
The undersigned applicant hereby consents to an investigation of his/her background including all records of
every kind and description including police records, tax records (State and Federal), and bank or lending
institution records, and said applicant and spouse waive any rights or causes of action that said applicant or
spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or
releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or
indirectly,a spousal affidavit of non-participation may be attached.
The undersigned understand and acknowledge that any license issued, based on the information submitted in
this application, is subject to cancellation if the information contained herein is incomplete, inaccurate, or
fraudulent.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28, CFR, 16.34.
411/21_/4- "1-1-17-,- --1 •
ignature of Manager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of VOC,Q14 5 The foregoing instrument was acknowledged before me this
•
gleP ✓ 11C i O by Vil(iievIA Lf6e.',n (0 II erpt 6c'✓iytt,it/
date NAME OF PERSON BEING ACKNOWLEDGED
Affix Seal
NotaryPublic signature GENERAL NOTARY-State of Nebraska
gn BRIAN T SKOGERBOE
My Comm.Erp.January 10.2019
•
e , " uh.Kavy (vi:N-c:t`f,
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.
Form 103
Rev July 2018
Page 6 of 6
SPOUSAL AFFIDAVIT OF Office Use RECEIVED
NON PARTICIPATION INSERT
OCT 012018
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRASKA LIQUOR
LINCOLN,NE 68509-5046 •
PHONE:(402)471-257 I CONTROL COMMISSION
FAX:(402)471-2814
Website: www.lcc.nebraska.gov `
>< I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will
not have any interest, directly or indirectly in the operation of the business (§53-125(13)) of the Liquor Control
Act. I will not tend bar, make sales, serve patrons, stock shelves, write checks, sign invoices, represent myself
as the owner or in any way participate in the day to day operations of this business in any capacity. The
penalty guideline for violation of this affidavit is cancellation of the liquor license.
I acknowledge that I am the applicant of the non-participating spouse of the individual signing below. I
understand that my spouse and I are responsible for compliance with the conditions set out above. If, it is
determined that my spouse has violated(§53-125(13))the commission may cancel or revoke the liquor license.
. lieel-4_. .dy-a,i,„-,
/7---/----i . - .4.....„.„:„___, _.,
Signature of NON-PARTICIPATING SPOUSE Signature of APPLICA
Uef(,se4 Coe,4r1f?4 6)111(4rrl f Cr(a')9rl
Print Name Print Name
State of Nebraska,County of 00W,1(5 State of Nebraska,County of Of uy 4 f
The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me
this 5ePier,17et': , c, 0l b' (date) this '�.kirt.4'% )S 4)0/"6 (date)
by L C f I ClS -&C(,v.. by tAll �/I z L ec n Scf/✓
Name of person acknowledged Name of person acknowledged
(Individual signing document) • (Individual signing document)
$I r /—s
Notary Public Signature • Notary Public Sigture
GENERAL NOTARY-State of Nebraska GENERAL NOTARY Slate of Nebraska
BRlpyr}Ila9!'�GERBOE BRIA Ix{sSICOGERBOE
ter.�` My Comm.Exp.January 10,2019
My Comm.Exp.January 10,2019
eyo.:i i4-1.....2hlc;,>C.4.e. ty.e. �71.,..e.y,o,.),)i,,
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 I 1
•
PRIVACY ACT STATEMENT/
Off SUBMISSION OF FINGERPRINTS ' RE ` only
OF FEES TO NSP-CID CEIVED
NEBRASKA LIQUOR CONTROL COMMISSION O C T O 1 2018
301 CENTENNIAL MALL SOUTH
PO BOX 95046 WORM MUM OR
LINCOLN,NE 68509-5046 CONTROL COMMISSION
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
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: "giqt, 7)I-n L o U N G F
Name of Person Bring Fingerprinted: LA ;1/.q rn C l a n g is
Date of Birth: , Last 4 SSN:_ Date fingerprints were taken: 7-Q v- / g
Location where fingerprints were taken: '/y/1 So /? ' , 12e 4'> 31
How was payment made to NSP?
ONSP PAYPORT ❑CASH ❑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 ❑
,✓/7
SIGNATUR'E REQUIRED OF PERSON BEING FINGERPRINTED
FORM 147
REV MAY 2018
City of Omaha, fArebras&a
-,4111
1819 Farnam —Suite LC 1 z �1g .i.; +r5 Llt
Omaha, Nebraska 68183-0112 c16, v.r' rg.,,,�.
Elizabeth Butler (402) 444-5550
CityClerk FAX 444-5263 � ry
(402)
TFD FEPO'
November 6, 2018
Tangier Temple Holding Corp Application to appoint William E. German
Dba"Bagdad Lounge" manager of your present Class "C"Liquor
2823 South 84th Street License location
Omaha,NE 68124
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to
appoint a manager to the liquor license has been set for November 20, 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,
•
Eliza eth Bu r
City Clerk
EB:clj
Cityo - Omaha, fAre bras a
t.
ArilV
1819 Farnam — Suite LC 1 z lr,�.i ,Pik) itt
Omaha, Nebraska 681 83-01 1 2 S ; ,>*Wili'^
Elizabeth Butler (402) 444-5550 `
City Clerk FAX (402) 444-5263 z-
9TFD FEBR‘ P
November 6, 2018
William E. German Application to be appointed manager of the present
4841 South 92nd Avenue Class"C"Liquor License location for Tangier
Omaha,NE 68127 Temple Holding Corp., dba"Badgad Lounge",
2823 South 84th Street
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to be •
appointed manager of the liquor license has been set for • November 20, 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,
G .J
Cam;
Elizabeth Butler
City Clerk
EB:clj