RES 2016-1709 - Appoint Shelby M Goodrum manager of Travel Design Lounge E-MAILED TO NLCC
44. STATE OF NEBRASKA
,
. r;). .
4", ; Pete Ricketts IL. NEBRASKA LIQUOR CONTROL COMMISSION
t r./ Governor Hobert B.Rope
4e4 • Executive Director
301 Centennial Mall South,5th Floor
%Nee.
MANAGER RECOMMENDATION P.0 Box 95046
Lincoln.Nebraska 68509-5046
Phone(402)471-2571
DATE: December 8, 2016 Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
web address http;//wwwlccne.gov/
TO: City Clerk of Omaha E-MAIL:carman.johnson@cityofomaha.org
MANAGER: Shelby M Goodrum
LICENSEE: Travel and Transport dba Travel Design Lounge
LICENSE#: C-113036
DUE DATE: January 23, 2017
Attached is a copy of a new manager application submitted to Nebraska Liquor Control Commission.
Please complete the following to submit your recommendation. Send back to Tracy Burmeister at
tracy.burmeisteramebraska.gov or fax to(402)471-2814,with questions call (402)471-2572.
APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS: /Yip /41/70 Dec kv, Lae 02o, ,-22di
(May attach minutes and/or additional notes)
CLERKS SIGNATURE:
DATE: P2A/A2 6/
1600'022606
Janice M.Wiebusch Robert Batt Bruce Bailey
C01,11 ,,s,cmor Chanmcm Commrssloner
An Equal Opportunt4 Employer
61MiNzeinsanc
Dec. 8. 2016 3:48PM No. 0780 P. 3
MANAGER APPLICATION Office Use :
INSERT-FORM 3c
DE 0 A 2016
NE13RASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO PDX 95046 s i_i 1 0 4
LINCOLN,NE 68509-5046 (J
PHONE:(402)471.2571
PAX:(402)471-2814
Website:www.lce.nebraska.gov
MUST BE;
• Citizen of the United States, Include copy of US birth certificate,naturalization paper or current
passport
✓ Nebraska resident. Include copy of voter registration card or print out document froJ,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:Travel and Transport
iffiemises information ,
Liquor License Number: 11303 6 Class Type�✓ (if near optional)leave blank)
Premises Trade Name/I�IIA:Travel Design Lounge
16950 Wright Plz Suite 151
Premises Street Address; g
City:Omaha County:Douglas Zip code:68130
Premises Phone Number; 02-399- 77
Premises Email address:ContactUs@traveldesignlounge.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.ktgt
{ AT'i]RE REQUIRED BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
tr Farm 103
REV AUG 2016
Page 2 aid
Dec. 8, 2016 3:48PM No. 0780 P 4
Manager's information must be completed below PLEASE PRINT CLEARLY
Last Name:Goodrum First Name:Shelby mi:m
iNtceo, SKI; yo),
Home Address:9113 Westridge Dr cchTrm,_
City;Omaha Douglas 68124
County: Zip Code:
- -
Home Phone Number:7192878233
Driver's License Number&State:NE
Social Security Number:
Date Of Birth: place of Birth:Colorado Springs, CO
Email address:sgoodrum@tandt.com
eortiftleteteinitses irifeintstibit(Evtaita spensal efildaltit,has been submitted)
YES FLNO
: — •
Spouses Last Name: First Name: MI:
Social Security Number;
Driver's License Number&State:
Date Of Birth: Place Of Birth:
OP0.0E.WitiStV4TRESIONCE(8) OR 1)*PAST TEN:(10)YEARS
' ATPACANT SitiUSE
YEAR YEAR YEAR CITY&STATE CITY&STATE YEAR
FROM TO FROM TO
Omaha, NE 2011 2016
Colorado Springs, CO 1990 2011
Form 103
REV AUG 2016
Page 3 af 6
Dec, 8, 2016 3:49PM No, 0780 P. 5
M 'NAOER'S LAST TWO EMPLOYERS .
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO r;; () E+R
2015 2016 Addy's Bar and Grill Mark Bryant 402416175267
l l #K
2012 2015 Clancy's Pub Todd Gaddy, . : 4 627•
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,
gl YES fl NO
If yes,please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mrn/yyyy) (City&State) Char:e
Shelby Goodrum 09/2009 Denver, CO Speeding guilty
Shelby Goodrum 03/2010 Cobradosprings,co Careless Driving guilty
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
EYES %NO
IF YES, list the name of the premise(s):
3. Do you,as a manager,qualify under Nebraska Liquor Control Act (453-131.01) and do you intend to
supervise,in person,the management of the business?
�ES CO
Form 103
REV AUG 2016
Page 4 or 6
Dec. 8. 2016 3:49PM No. 0780 P. 6
4. List the alcohol related training and/or experience(when and where)of the pers.** .liinkaPP164ott.
G
*h/CC Training Certificate issued: RB-0072554 Name on Certificate: Shelby oodwin
NE' PA
C.,CT Pt.
Date
Applicant Name ( TI/YYYY) Name of program(attach copy of course completion certificate)
1111
Shelby Goodrum 11/2016 Nebraska Responsible Beverage Service Training
Shelby Goodrum 10/2012 TIPS
For list of NLCC Certified Training Programs see training
Experience:
Date of
Applicant Name/Job Title Name&Location of Business:
Employment:
Shelby Goodrum/Manager 9/15-current Travel Design Lounge - Omaha, NE
Shelby Goodrum/Bartender 4/15-current Addy's Bar and Grill - Millard, NE
Shelby Goodrum/ Manager 2113-4/15 Clancy's Pub Omaha, NE
Shelby Goodrum/bartender 9/11-2/13 Brewsky's - Ralston, NE
5. Have you enclosed fm 147 regarding fingerprints?
-,t-YES NO
Form 103
'REV AUG 2016
Pogo of 6
Dec. 8. 2016 3:50PM No, 0780 P. 8
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STATE OF NEBRASKA
LIQUOR CONTROL COMMISSION
LICENSE NUMBER RETAIL
OWNERSHIP C I - INDIVIDUAL
CLASS C • ALCOHOLIC LIQUOR ON/OFF SALE P - PARTNERSHIP
(INSIDE CORPORATE LIMITS) C - CORPORATION
* * * * * * * * * * * * BOND INFORMATION * * * * * * * * * * *
BOND COMPANY START DATE CANCEL DATE
BOND NUMBER
BOND AMOUNT FED BASIC PERM I'I' #
* * * * * * * * * * * * RESTRICTIONS * * * * * * * * * * * * * * *
* * * * * * * * * * * * PREMISES INFORMATION * * * * * * * * * * * * *
TRADE NAME 1 TRAVEL DESIGN LOUNGE LICENSE NO.
TRADE NAME 2
ADDRESS-1 16950 WRIGHT PLAZA ADDRESS-2 SUITE 151
CITY OMAHA COUNTY 01 DOUGLAS ZIP 68130
PHONE 402 548 3280 FAX
MAIL TO:
NAME TRAVEL AND TRANSPORT
ADDRESS-1 2120 S 72 STREET ADDRESS- SUITE 700
CITY OMAHA STATE NE ZIP 68124
* * * * * * * * * * * LICENSE DESCRIPTION * * * * * * * * * * *
SINGLE STORY BLDG APPROX 79'X 24' INCLUDING L-SHAPED OUTDOOR
AREA APPROX 22 ' X 52'
* * * * * * * * * * * * GENERAL INFORMATION * * * * * * * * * * * * * *
CORP. OWN LEASE REPLACING TOP SUSPENDED LICENSE EXP
LIMITS PREMISES EXP. LIC. NO. EXP. START DAYS DATE
(Y OR N) (Y OR N) DATE DATE
Y N 12312020 10312017
EMAIL: CONTACTUS@TRAVELDESIGNLOUNGE.COM
ACTION DATE DOCUMENT NO. ROLL PAGE ACTION CODE
DEPRESS: ENTER - PROCESS PF11 - INQ NOTES PF12 - HISTORY PA1 - RETURN TO MENU
Dec. 8, 2016 3:49PM No, 0780 P. 7
f t: . •;Ri"6001^60 e El I; �• 'Y T G ON,
The above individual(s), being first duly sworn upon oath, deposes and states igit rsigned is the
applicant and/or spouse of applicant who makes the above and foregoing appli Iittil41401ppiistation has
been read and that the contents thereof and all statements contained therein arc truer 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&53-01,0O 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 Nottcatlon 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.
Signat of anager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State ofNelgaska
County of VII U The foregoing instrument was acknowledged before me this
Wet.tLel/ [ 70IIP _ by st,el�y rc
/ date NAME OF PERSON BEING ACKNOWLEDGED
Y 1 r
� - AffixSeai
Notary Public signature :ERAL WAIT.IS L� Et pT
M Comm.Eep.tiov,7,2017
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
Pogo 6 of6
Dec, 8, 2016 3:51PM No, 0780 P. 11
SUBMISSSION OF FINGERPRINTS 1 b . p 1
PAYMENT OF FEES TO NSP-CID twfriitttElq6
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 s .
LINCOLN,NE 68509-5046 ` e linty
PHONE:(402)471-2511
FAX:(402)471.2814
Website:www.lcc,nebraska,gov Class: License ti:
Applicant Name: ,rYf t
(Corporation,L[.tC,Partn I !v► usid ) �1''`"'
TrudeName; -crave‘ Drsz 1L71Yi �,...{'ll) ,,
(Doing Business As) J
(001)311— 4141 viXn cOr
Phone Number Contact E-mail Address
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• See Application Requirement Guide for listing of Fingerprint Requirements,found on our website under
"Licensing"tab in"Guidelines/Brochures". MIME TODLEZPIraRPRINT CARDS ANDJY
DINKBEEMZiklaTE PATROL WILL D L _Y
I$ A O Y R It YJJ55E $ E'e
• This completed form MIST be included with your Liquor License Application and/or Manager
Application or changes to;Corporate Offitera or Stockholders,LLC Members,Partners or Addition of
Spouse where new fingerprint cards are required(see New Application Requirement Guide).
• DO NOT send fee payments to the NLCC—fees MUST be paid directly to NSP,
Include a list of names cowered by your payment to Insure proper application of payment.
• Fee payment of$28.73 per person mg be made directly to the NSP;
It is recommended to make payment through the NSP PayPort online system at www.ne.cev/ao/nsp
Or checks made payable to NSP should be mailed directly to the following address:
The Nebraska State Patrol—CID Division
3800 NW 121"Street
Lincoln,NE 68521
• Fingerprints are not required for spouses that have no involvement with business Spousal Affidavit of
Non Participation(Form 116)is required in lieu of fingerprints.
• 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 MAR 2016
PACE 1
8 2016 3:51 PM No. 0780 P. 12
r
'
A,,�,,
Date of Last 4 SSN: _ .
l. Name:cS spISriLi...__._ ,_ _
(Please print legibly)
Fingerprints on tile with the commission? YES Mr
How was payment made to NSP? ONSP PAYPORT CICASH CICHECK SENT TO NSP Ck#
2. Name: . }y,
(Please print legibly)
Date of Birth: Last 4 SSN: _
Fingerprints on file with the commission? YES 0
How was payment made to NSF? ONSP PAYPORT OCASH OCHECK SENT !{Sr Ck#
3, Name
(Please print legibly) .,
Date of Birth; Last 4 SSN:
Fingerprints on file with the commission? YES O
How was payment made to NSP? ONSP PAYPORT °CASH OCHECK SENT TO NSP Ck#
4. Name;
(Please print legibly)
Date of Birth: _ _ Last 4 SSN;
Fingerprints on file with the commission? YES 0
How was payment made to NSP? ONSP PAYPORT OCASH OCHECK SENT TO NSP Ck#
S. Name: _
(Meese print legibly)
Dare of Birth: Last 4 SSN: ^_
Fingerprints on file with the commission? YES L.i
How was payment made to NSP? ONSI'1'.k fPOL i i 1CASH ❑CHECK SENT TO NSP Ck#
6, Name:
(Please print legibly)
Date of Birth; Last 4 SSN:
Fingerprints an file with the commission? YES 0
How was payment made to NSP? ONSP PAYPORT OCASH OCHECK SENT TO NSP Ck#
I hereby certify that fees of$28.75 per person have been submitted directly to the Nebraska State Patrol CID
office. The uoderaigoed certifies on behalf of the Corporation,LLC,Partnership or Licensee that it is understood
that a misreprosentatlou of feet is cause for rejection of this application or suspension,cancellation or revocation of
any licensee issued.
Name(Prtnt):; ) 1 r ) fl Ttget an er
$ nature Date:
FORM 147
REV JAN 2016
PAGE 2
Dec. 8. 2016 3:47PM Nlo 0780 P. 1
djA, 17} zo/p
Michelle Holmes •
To: Nebraska Liquor Control Commission
• r4,:;E,
301 Centennial Mali South
PO BOX 95046
qtqf
Lincoln,NE 68509-5046
Delivery via Fax 402-471-2814
r -4
From: Michelle Holmes,mholmes@travelandtransport.com
•
Attached are the forms needed to add Shelby Goodrum to Travel and Transport's liquor License,
Please send me an email confirmation of receipt. Also after review, please let me know what else is needed to add
Shelby Goodrum to the license or when it's completed.
Thank you.
Michelle Holmes,CEP, CTC
General Manager
Travel and Transport,Inc.
402-255-7874
402-301-4996
mhoirnaegtravelandiransoort.com
travelandtranaport.com
4I-traveland
',transport.
RadiusTravel
.1.4•11 IN I IIL
Wiiit I rnkihthil you vyilf idwayr.1I II tnnOi With your latugt 11.svol
Download this fro')mobilo apn Indoyi
Ma&
Citij of Omaha ,04o��HA7A'"?�
1819 Farnam —Suite LC 1 ��'�1ii �� _�1 ,�
Omaha, Nebraska 681 83-01 1 2 r' lr� '1 ,°
Buster Brown (402) 444-5550 ��,o ' ` �
ti
City Clerk FAX (402) 444-5263 o
'TFD FEBR��
December 9, 2016
Travel & Transport, Inc. Application to appoint Shelby M. Goodrum
Dba"Travel Design Lounge" manager of your present Class"C Liquor
16950 Wright Plaza, Suite 151 License location
Omaha, NE 68130
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 December 20, 2016 . 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,
A0 --Ye/re'r,-"No-
,:uster : 's i
City Clerk
BJB:clj
City of Omaha, TNebraska NIV,
p�AHA, �,
1819 Farnam — Suite LC 1
Omaha Nebraska 681 83-01 1 2 �v WV,
Buster Brown (402) 444-5550 ti
City Clerk FAX (402) 444-5263 o4,4
F 4"�
RFD EB'R��
December 9, 2016
Shelby M. Goodrum Application to be appointed manager of the present
9113 Westridge Drive Class "C" Liquor License for Travel & Transport,
Omaha, NE 68124 Inc., dba"Travel Design Lounge", 16950 Wright
Plaza, Suite 151
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 December 20, 2016 . 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,
Buster Brown
City Clerk
BJB:clj
ea(5
No. /76
Travel & Transport, Inc., dba "Travel Design
Lounge", 16950 Wright Plaza, Suite 151
requests permission to appoint Shelby M.
Goodrum manager of their present Class "C"
Liquor License location.
12-20-16;cj
RECEIVED
Presented to Council:
December 20, 2016 - Approved 7 o
Buster Brown
City Clerk