RES 2017-1218 - Hotel Deco XV appoints Janelle N Shank manager of class C liq lic loc E-MAILED TO NLCC 9'_l
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of r f o 1 r.A j 4 1 / r--
' �'' t-' �- ' STATE OF NEBRASKA
F a: :: •t.;1 Pete Ricketts ry i NEBRASKA LIQUOR CONTROL COMMISSION
kcw..a:` .; ..eo 20I r uC1• 3 A'e 5 Hobert B.Rupe
a'^*%� � 1 Governor ti..
�'`� �`I . 5f1► � Executive Director
'.yt -..-.._- . 301 Centennial Mall South,5th Floor
YyhRcrt ram+° r • P.O.Box 95046
t i. • Lincoln,Nebraska 68509-5046
Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
Web address http://www.lcc.nebraska.gov/
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• 10/6/2017 -
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To: CITY CLERK OF OMAHA
Email: CARMAN.JOHNSON@CITYOFOMAHA.ORG
• Manager Name: JANELLE N SHANK.
Licensee Name: APARIUM HOTEL GROUP LLC
Licensee Trade Name: HOTEL DECO XV •
License Number: C-119775
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Due Date: Monday, November 20, 2017
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 TRACY at tracy.burmeister@nebraska.gov or fax to 402-471-
2814. If you have questions concerning this matter, please contact our office at 402-471-2572.
APPROVED
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NO LOCAL RECOMMENDATION
DENIED
COMMENTS (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES):
ccy 1g$ . • O013/1wi7
✓30
Clerk Signature:
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Date: • ` 1-- I 't
Janice M.Wiebusch • Robert Batt
Commissioner Chairman
An Equal Opportunity Employer 1700012476
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MANAGER APPLICATION Mice Use
INSERT-FORM 3c
NEBRASKA LIQUOR CONTROL COMMISSION •
301 CENTENNIAL MALI.SOUTH
PO BOX 95046
i.iNCOLN,NE 68509-5046 •
PHONE:(402)471-2571
FAX:(402)471-2814
Wcbsite:www.lcc.nebrasska.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
✓ 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
Corporation/LLC information
�
r , II
Name of Corporation/T.LC: j (-�4 ' (L/4l r1�� • et1 ICI J- /4 pri i
Premises information .
Liquor License Number: " application I � � ?•7 s Class Type (if new n licrrian Icnvc blank)
Premises Trade Name/DBA: //O/r / / eco
Premises Street Address: I.;0"l 146,111,6() S-1
City:0 ryta Y p County:DDIAltac Zip Code: (08102_
Premises Phone Number: 7 C'v` `(// / 0>i
Premises Email address: JSh 1 r_69/1O! ldecoomahu.Com
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.
1
SIGNATURE REQI;ID BY CORPORATE OFFICER ! MANAGING MEMBER
(Faxed signatures are acceptable)
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Farm 103
ItliV AUG 2016
Wiiitger's infornifitiiiimustbe coMpleted below PLEASE PRINTtLEARLY
Last Name: 5 han First Name: jant1/6 MI:
Home Address: / 5 W tVflcj 5-0q
City: (7 ma lqe{ County 1901/19/4C Zip Code: 6'<fl2
Home Phone Number: C 2 - 7 ,zne
Driver's License Number&State: hatsta
Social Security Number: - — , - —- -
Date Of Birth: Place Of Birth: -110119)t,d LL 1/(ILLICt(
Email address: j6 tiv_p kaki de do ovo ei 0 0-3
ri YES Klictrr
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Spouses Last Name: First Name: MI:
Social Security Number.
Driver's License Number&State:
Date Of Birth: Place Of Birth:
Aitti.APOt*AloWit—WPV .
:*tglootterokliSiV•11404050.M•rix :711u.O.*Mtzviyif,..,i-,2:n .-;?..,.41
YEAR YEAR YEAR YEAR
CITY&STATE CITY&STATE
FROM TO FROM TO
(00/10 ht IN I 62ô(1-1 20/ 7
geNikte— IUC 7 2411
Form 103
REV AUG 2016
Page 3 of 6
at
YEAR TELEPHONE
FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR NUMBER
2UR I 20r7 crane ' /ai' , ; airy yid 3'i7
20rs" 204 /iY w- ) f/e 9, ,9is 7(2-32,-1&r
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 FY NO
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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
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2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
FIVES 0 .
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
supers/ e,in person,the management of the business?
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ES FINO
Form 103
REV AUG 2016
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: Name on Certificate:
Applicant Name ( tyyy ) Name of program(attach copy of course completion certificate)
mIT*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
5. Have ou enclosed form 147 regarding fingerprints?
S aNO
• Form 103
REV AUG 2016
Page 5 of 6
R•
714-WWWITANDVONOrgtAltittiNt :7Mr'W''''
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 Signature of Spouse
ACKNOWLEDGEMENT
State of Nebraska r
County of The foregoing instrument was acknowledged before me this
C I c' e ' ;,L1:I 1 by , C� lc�. %L:1.1'1
date NAME OF PERSON BEING ACKNOWLEDGED
/l
1 n n� '� C✓i } ) Affix Seal GEALRAL NOTARY-State O}Nebraska
o Public signature AMA Il EDA
*Comm Exp.February 21,2021
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 AUG 2016
Page 6 of 6
SUBMISSSION OF FINGERPRINTS /
PAYMENT OF FEES TO NSP-CID r ? r•�/4r
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE: (402)471-2571 Office Use Only
FAX: (402)471-2814
Website: www.lcc.nebraska.gov Class: _. License#:_._
Applicant Name: Uae1( - Jr wwnt,- Vh ViI ' , `e Aftd L3a.r
(Corporation,LLC,Partnership or Individual)
Trade Name: V Q Vla vat 6rale., a►4CJ 6ar/ 14-0-id Teat)
(Doing Business As) •
'141� Wei jchin 711-00(eorbacd at cDni
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;
• 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 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.
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Please complete information on the following pages for EACH person fingerprinted. ..---..
FORM 147
REV DEC 2016
PAGE 1
1. Name:darlefIC Chao Date of Birth:;. Last 4 SSN:
Date fingerprints were taken: /0/3// 7 Location where fingerprints were taken: .S &kit It
How was payment made to NSP? ❑NSP PAYPORT ❑CASH WCHECK 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 ❑
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 ❑
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 ❑
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—fmgerprints 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): ne-1 It 11 L Title: n1na9e 1'
Ltzi 10� / 7
Signature: 3�Date: l Lilo/-
FORM��
FORM 147
REV DEC 2016
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ORIGINAL CHECK IS PRINTED ON CHEMICAL REACTIVE PAPER AND HAS MICRO PRINTING IN THE SIGNATURE LINE
Hotel Deco Xt/ `: r� ; UM ' Bank : .:,: .011518
1504 Harney St OperatIErg
Omaha;•NE 68f02 r �
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. "3..y `.c0 e '` a - .. - Q'
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k1 M F l.
PAY
Forty Flue anal ii:00 D liars ;4
'f Check No BATE r AMOUNT'
031518
1/2/2017 $45.25
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TO THE Nebraska State Patrol erD Divislon ... . 7®� ' • .
I ,
ORDR,; • �`®
OF 3800 NW 12th Street
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r.;
•1.incoln0E A$521 ,ti AUTHORIZED S ATURE, . p�
# . . k} a ? r, , .: AUTHORIZED SIGNATURE 1Yp
"VERIFICATION BOX"(TO RIGHT OF ARROW,HOLD BETWEEN THUMB AND FOREFINGER,OR BREATHE ON IT,COLOR WILL DISAPPEAR,THEN REAPPEAR) .
II'O L L5 L80 I: LO L000695': 987 L9 L45 2611'
. 011518
Hotel Deco XV
Date Invoice No. Invoice Date Description Amount
9/3/2017 09012017 9/1/2017 Liquor License- Fingerprinting fee for Janelle Shank 45.25
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Check> 10/2/2017 check > 011518 Total) 45.25
Date Number
REORDER FORM TP1-2S MP BIRMINGHAM.AL 35216(8001 366-3194
City of Omaha We6raskg. 4\\
v �71
1819 Farnam —Suite LC 1
, 1y
Omaha, Nebraska 68183-0112 o AL- 1 45 ,
Elizabeth Butler (402) 444-5550 c,
City Clerk FAX (402) 444-5263 0�
94
E1)
FEBRVA
October 17, 2017
Aparium Hotel Group, LLC Application to appoint Janelle N. Shank
Dba"Hotel Deco XV" manager of your present Class"C"Liquor
1504 Harney 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 October 31, 2017 . 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
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�1v1A A,
,v
City ofOmaha, Nebraska %
1819 Farnam — Suite LC 1 z K i tat II
Omaha, Nebraska 681 83-01 1 2
Elizabeth Butler (402) 444-5550 �,o` ti,
City Clerk FAX (402) 444-5263 04)9___
1FDF030
October 17, 2017
Janelle N. Shank Application to be appointed manager of the present
1520 Harney Street,Apt 504 Class"C"Liquor License locations for Aparium Hotel
Omaha,NE 68102 Group, LLC, dba"Hotel Deco XV", 1504 Harney Str
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 October 31, 2017 . 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
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