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RES 2018-0568 - Appoint Ellie F Novak manager of class I/K liq lic loc at Bemis Center for Contemporary Arts E-MAILED TO NLCC 4 <v Y �.; t �J l_ ` L. STATE OF NEBRASKA G: .• Pete Ricketts ,� NEBRASKA LIQUOR CONTROL COMMISSION +`++� * q ` PM 12. 58 Hobert B.Ru e ' <�;J Governor NIB t iN '7 p ar a i R ..r y • Executive Director • • 301 Centennial Mall South,5'"Floor • CITY CLERK • P.O.Box 95046 Lincoln,Nebraska 68509-5046 C M A H , ti El., S K Phone(402)471-2571 • Fax(402)471-2814 or(402)471-2374 TRS USER 800 833-7352(TTY) Web address http://www.Icc.nebraska.gov/ 5/3/2018 To: CITY CLERK OF OMAHA Email: CARMANJOHNSON@CITYOFOMAHA.ORG • Manager Name: ELLIE F. NOVAK • Licensee Name: BEMIS CENTER FOR CONTEMPORARY ARTS • Licensee Trade Name: BEMIS CENTER FOR CONTEMPORARY ARTS License Number: IK-84061 Due Date: Monday, June 18, 2018 • I have attached a copy of a new manager application that was submitted to the Nebraska Liquor Control Commission. Please complete the following information below to indicate your• recommendation. Send back to Shelah at shelah.davis@nebraska.gov or fax to 402-471-2814. • If you have questions concerning this matter, please contact our office at 402-471-2572. APPROVED NO LOCAL RECOMMENDATION DENIED • COMMENTS (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES): a' ) 4 .1 ier • • • / 2 Clerk Signature: (7:7' _ Date: Lei �// • • Janice M.Wiebusch Robert Batt Commissioner Chairman An Equal Oppuriunity Employer 1800006092 RECEIVED MANAGER APPLICATION Office Use INSERT-FORM 3c MAY 03 2018 NEBRASKA LIQUOR CONTROL COMMISSION NEBRASKA LIQUOR 301 CENTENNIAL MALL SOUTH PO BOX 95046 CONTROL COMMISSION LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX:(402)471-2814 Website:www.Icc.nebraska.gov MUST BE: • ✓ Citizen of the United States. 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 V 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 tb..' �c.xE,: Y _ 1 M.v Yam"• COrpt5r8t1021�..L�"1t1�01Y!]��idn � ` > ... , Name of Corporation/LLC: NAM I S C JV'V t€V Y (ion-fer rora ry a--s Premise infoanation p Liquor License Number: D 0 to I Class Type 1 K (if new application leave blank) Premise Trade Name/DBA: L, Premise Street Address: 72� G • l� City: e ,Ail A County: Pou5'u S Zip Code: (PuC. �' 2 /�. f' • Premise Phone Number: -f nn3 i4 I /� D Premise Email address: / o l� be.w i S Ge/t".-tt r, 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 information here. Fed C l aii SIGNATURE REQUIRED BY CORPORATE OFFICER/MANA MBER (Faxed signatures are acceptable) •Form 103 Rev Jan 2018 Page 2 of 6 MANAGER APPLICATION Office Use RECEIVED • INSERT-FORM 3c MAY 0 3 2018 NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR PO BOX 95046 LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE:(402)471-2571 FAX:(402)471-2814 Website:www.Icc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: • Complete all sections of the application. Be sure it is signed by a member or corporate officer, corporate officer or member must be an individual on file with the Liquor Control Commission • Fingerprints are required. See form 147 for further information,read form carefully to avoid delays in processing,this form MUST be included with your application. • Provide a copy of one of the following: US birth certificate,naturalization papers or current US passport(even if you have provided this before) • Be a registered voter in the State of Nebraska, include a copy of voter card or print document from Secretary of State website with application jpouse who will not participate in the business,spouse must: <. • Complete the Spousal Affidavit of Non Participation Insert(must be notarized). The non- participating spouse completes the top half;the manager completes the bottom half. Be sure to complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business,the spouse must: • Sign the ap lication • Fingerprints are"require• ee form 147 for further information,read form carefully to avoid delays in processing,this` o v MUST be included with your application. • Provide a co. of one f the following: birth certificate,naturalization papers or current US passport (even if y• have provi d this before) • Be . registered voter in the sta of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participatio Insert not required Form 103 Rev Jan 2018 Page 1 of 6 Manager's information muSt be completed below ',PLEASE PRINT CLEARLY Last Name: (J Ov ale First Name: E1 i t, MI: Home Address: ? to 0 7 $. 7 4th S4 • City: O rnah o' County: Oc,.>3I"3 Zip Code: to e i I`I- Home Phone Number: (,9 i`k) S'3 C - a a7- ( 1I 0'bras_A Driver's License Number& State: Social Security Number: Date Of Birth: Place Of Birth: Email address: Q.k %-e- @ Ier„,S c en4e,-o Are you married?If yes,coniPlete Spouse's information ven ifii Spousal affidavit has been subr i (YES ❑NO Spouse'$informatiotl Spouses Last Name: N a Y a' First Name: Do n MI: C9 • Social Security Number: _ Driver's License Number& State: - - - . - 1\.) Date Of Birth: ` Place Of Birth: VI Scu l er Ac'8 h4 APPLICANT&.SPOUSE MUST LIST RESIDENCE(S)FUR THE PAST TEN 0114 YEARS Al'PLICAT T ..- 5Pf►liJSE . ., ...,- .��^.,�' �:'. :,..... CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO ornp,M, Ne 4,Cib aoi7 Qrnaha , N E. aoily ,;1o17 r12e12.11n 1 r`1`4 a00 7 aois grvo+a n 1 E. aoc 7 a o15 Form 103 Rev Jan 2018 Page 3 of 6 I4 ASAGER'S ST TWQ+EM• LOYER$ YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER goof- aol) 1-4.6.,,poitari OkSeuM of Air Ge re/ &+aro C .ta) (os-o— 4 iS a'°o`f' ol;eao HrrarYp�tnuit Ab►-nad Tj rn Fri Oct ndkr c a►d.)6i�-}- gdi.�.i 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. 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 �tt‘ Nova le. 03 Iaoito °mak( JE S aij t,r1,c. Ftt& CIasS E11,.e No✓a2 4303.3 -ri1 or;,cf 1J1� Srcj,nq -t. -Poe- e.r'd 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYESNO IF YES, list the name of the premise(s): 3. Do you, as a manager, qualify under Nebraska Liquor Control Act(§53-l 31.01) and do you intend to supervise, in person,the management of the business? [YES LINO Form 103 Rev Jan 2018 Page 4 of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued: C4r1 4 Name on Certificate: E1 t`C N.)0`'°-le: Applicant Name Date Name of program(attach copy of course completion certificate) (mm/YYYY) E\1,e. Ncui«k- 4pL4 j0,018 sv.r-2Sct1 Nictv3 *For list of NLCC Certified Training Programs see training Experience: Applicant Name/Job Title Date of Name&Location of Business: pp Employment: .5tl,e IN) /Oveto?mri 3/ t /J-0 cern;S ( 4er -or Conk/1,orcl Ats D;re ci-of 7d.`f S, I a.-f h 4 I oma-hckJ N E 6 &1 Oa- 5. Have you enclosed form 147 regarding fingerprints? RYES . • Form 103 Rev Jan 2018 Page 5 of 6 SureSeH \ ow • Responsible Alcohol Server Certification This Certificate of Completion is to Certify that Ellie Nova C has met all training requirements and successfully completed the following course and/or exam. SureSell Nebraska Alcohol Server Training Completion Date: April 26, 2018 Expiration Date: April 25,2021 Certificate Number: 49254 Jir&a4j-daitc48., This course is approved by the Nebraska Liquor Control Commission (LCC). This training complies with all standards under Title 237 of Nebraska State Law. Authorized Signature Diversys Learning, Inc. 1 101 Arrow Point Drive, Suite 302 Cedar Park,TX 78613 SureSellNow.com • • PERSONAL OATH AND CON5E24T:OF INVESTIGATION 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. Signature of Manager Applicant Sig ure of Spouse ACKNOWLEDGEMENT State of Nebraska County of -0,7,./..Ct,Lt5 The foregoing instrument was acknowledged before me this W n I 3o, by Ott 2 N.oJc� IG date NAME OF PERSON BEING ACKNOWLEDGED Affix Seal Notary ublic signatures ' 'job:InuumioHNs°t4taSbMd 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 Jan 2018 Page 6 of 6 • SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH �] PO BOX 95046 RECEIVED LINCOLN,NE 68509-5046 PHONE:(402)471-2571 . FAX:(402)471-2814 MAY 0 3 2018 Website: www.lcc.nebraska.gov NEBRASKA LIQUOR rVi1 acknowledge that I am the spouse of a liquor licensPINI.'Q y ssiiggnature�ieelo�wrconfirms 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 penalt guideline for violation of this affidavit is cancellation of the liquor license. rvly 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. vs____. % /1.---- • Signature of NON-PARTICIPATING SPOUSE Signature of APPLICANT pv4J N vV-4c_ L)\tom. N a r a k2, • Print Name Print Name State of Nebraska,County of DOLA1,Ct. S State of Nebraska,County of .D vL,_etQQ.S •The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me this N f- 30,i �O(g (date) this 414 f 1 ` 30 l a 0 (date) • by D'v(l of GLA[ by 0`1 e. 1\c7 J Cvl•C • — • Name of person acknowledged Name of person acknowledged • (Individual signing document) (Individual signing document) Notary Public Si a ure Notary Public Signat re 6enerel Mclr,y•NNW fir. 6wratl Way.Steoe el Nebraska My. 3431 My Com.Es.Nov.XL2018. • 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 1 i SUBMISSION OF FINGERPRINTS/ RECEIVED t PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION MAY 0 3 2.08 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRASKA LIQUOR LINCOLN,NE 68509-5046 CONTRcP61510N PHONE:(402)471-2571 FAX: (402)471-2814 Website: www.lcc.nebraska.gov Class:_ License#:_. Applicant Name: 130 t(c C Q r r (491,1fiet l,..totTYLt✓y art S (Corporation,LLC,Partnership or Individual)) / Trade Name: (Doing Business As) A- *41 7l i O 114) bawl t sr��t ! U✓ Phone Number Contact E-mail Address DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED PROCESSING FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE. • See Application Requirement Guide for listing of Fingerprint Requirements found on our website under "Licensing"tab in "Applicant Guidlines". • DO NOT send fee payments to the NLCC—fees MUST be paid directly to NSP. Pal d 3/Zq/l E - 5 ee Attacked • Fee payment f$45.25 a person MUST be made DIRECTLY to the Nebraska State Patrol; It is recom ended t make payment through the NSP PayPort online system at www.ne.gov/go/nsp Or a check m 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 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 will be released to the applicants; Fingerprint cards should be submitted with the application. Please complete information on the following pages for EACH person fingerprinted. FORM 147 REV JAN 2018 PAGE 1 _ 1 1. Name: I I% N ovak- Date of Birth: _ Last 4 SSN: Date fingerprints were taken: 4+I/7f I g Location where fingerprints were taken: Omaha Igo\,ra TX t. S th How was payment made to NSP? 1SP PAYPORT ❑CASH ❑CHECK SENT TO NSP Ck# S� My fingerprints are already on file with the commission—fingerprints completed for a previous application less than 2 years ago YES 0 2. Name: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSP 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 0 3. Name: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSP 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 0 4. Name: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSP 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 0 • 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. I hereby certify that fees of$45.25 per person have been submitted directly to the Nebraska State Patrol—CID office. The undersigned certifies on behalf of the Corporation,LLC,Partnership or Licensee that it is understood that a misrepresentation of fact is cause for rejection of this application or suspension,cancellation or revocation of any license issued. Name(Print): �t i Q N ovc4.12- Title: Signature: Date: '-f'1 FORM 147 REV JAN 2018 PAGE 2 Point-of-Sale Payments https://otc.cdc.nicusa.com/PublicReceipt.aspx?src=csh pm p Rx PURCHASE RECEIPT Nebraska State Patrol - Criminal Identification Division RECEIVED 3800 NW 12th Street, Suite A Lincoln NE 68521 MAY ,; 3 I'? (402)479-4971 Antonina.Anderson-Trumble@nebraska.gov NEBRASKA LIQUOR OTC Local Ref ID: 23664002 CONTROL COMMISSION THANK YOU FOR.USING THE NEBRASKA STATE PATROL PAYPORT SERVICE Status: APPROVED Customer Name: Aileen Tobin Type: Visa Credit Card Number: **** **** **** Total Amount Charged USD$46.38 Items Location • Quantity TPE Order Total ID Amount Liquor License 1 28309080 $45.25 Applicant Name: Ellie Novak Date of Birth: _ Last four digits Soc. Security Number: _ _ Total remitted to the Nebraska State Patrol - Criminal $45.25 Identification Division 1 of 1 3/24/2018, 3:48 PM • ONIANA, �,� City cf Omaha, Webraska ° . r' .MalibWirTa i i ' 1819 Farnam -Suite LC 1 z ��lrI ,, Omaha, Nebraska 681 83-01 1 2 r, l -t - ;, '^ Elizabeth Butler (402) 444-5550 ,0 = : p City Clerk FAX (402) 444-5263 - 4 May 22, 2018 Bemis Center for Contemporary Arts Application to appoint Ellie F.Novak Dba"Bemis Center for Contemporary Arts" manager of your present Class "I/K" Liquor 724 South 12th Street License location Omaha,NE 68102 Dear Liquor License Applicant: This letter is notification that a hearing before the Omaha City Council on your application to appoint a manager to the liquor license has been set for June 5, 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 ® Omaha, f,Alebras&aCity -� 1819 Farnam —Suite LC 1 z E1410 ;c �ihlt. n Omaha, Nebraska 681 83-01 1 2 r_�Ll Elizabeth Butler (402) 444-5550 City Clerk FAX (402) 444-5263 o4, 4� 42, FEBR�� May 22, 2018 Ellie F. Novak Application to be appointed manager of the present 1607 South 79th Street Class "UK"Liquor License location for Bemis Center Omaha,NE 68114 for Contemporary Arts, dba"Bemis Center for Contemporary Arts", 724 South 12th 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 June 5, 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 City o . Omaha fArebraskg \ , 4) 1819 Farnam —Suite LC 1 �*'` ,` � ir Omaha, Nebraska 68183-0112 0 r r 1 �; /12 Elizabeth Butler (402) 444-5550 �,.. CityClerk FAX (402) 444-5263 TFD FEB03A May 30, 2018 Bemis Center for Contemporary Arts Application to appoint Ellie F. Novak Dba"Bemis Center for Contemporary Arts" manager of your present Class "UK" Liquor 724 South 12th Street License location Omaha,NE 68102 Dear Liquor License Applicant: This letter is notification that a hearing before the Omaha City Council on your application to appoint a manager to the liquor license has been set for June 12, 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 City qfWebraskg 9 s r- L 1819 Farnam —Suite LC 1 04 1 s t, Omaha, Nebraska 681 83-01 1 2 �Nr, r,, ' 'l Elizabeth Butler (402) 444-5550 • = ti, City.Clerk FAX (402) 444-5263 kJ ¢� 94 4. 0 F 00°3' May 30, 2018 Ellie F.Novak Application to be appointed manager of the present 1607 South 79th Street Class "UK"Liquor License location for Bemis Center Omaha,NE 68114 for Contemporary Arts, dba"Bemis Center for Contemporary Arts", 724 South 12th 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 June 12, 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 But.er City Clerk EB:clj