RES 2016-1581 - Appoint Cecil J Austin manager of 3-5-7 Club E-MAILED TO NLCC
H .
STATE OF NEBRASKA
Pete Ricketts,n r 1.ro F NEBRASKA LIQUOR CONTROL COMMISSION
\ 4v. Governor Le It, ‘,Lj — Hobert B.Rope
. Executive Director
301 Centennial Mall South,5th Floor
MANAGER RECOMMENDATION P.O.Box 95046
Lincoln,Nebraska 68509-5046
Phone(402)471-2571
DATE: October 28, 2016 Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
TO: City Clerk of Omaha E-MAIL: carman.johnson@cityofomaha,org
weir,auarows.http//www lcc ne goy,/
MANAGER: Cecil J Austin
LICENSEE: Most Worshpful Prince Hall Grand Lodge dba 3-5-7 Club
LICENSE#: C-01519
DUE DATE: December 16, 2016
•
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.burmeisterftnebraska.goy or fax to(402)471-2814,with questions call (402)471-2572.
APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS: ( JD 5 6C /L) i/eitilkek_ ,aoy ,
(May attach minutes and/or additional notes)
CLERKS SIGNATURE: GOP
DATE: Aidove,,A .QXy 0141,‘
•
01111 Hill 0
1600020787
Janice M.Wiebusch Robert Batt Bruce Bailey
n sstoner
Chomman Commissioner
An Equal Op pot tuuit Employer
MANAGER APPLICATION office Use
e e
INSERT-FORM 3c
NEBRASKA.LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE (402)471-2571
FAX:(402)471-2814
Website:www.lce.nebrasks.gov
MUST BE:
V Citizen of the United States, Include copy of US birth certificate.naturalization paper or current US
121121221:1
Nebraska resident. Jnclude copy of voter registration card or print out document from
I Fingerprinted. See 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
Name of Corporation/LLC: t)5 I .1k.0104.5407.14-1 6 CI 01 (aCir.3.L.
Premises information
Liquor License Number. 01519
Class Type Of new applicatioe leave blank)
3-5-
Premises Trade Name/DBA 7 Club:
Premises Street Address2414 AMES AVENUE
OMAHA DOUGLAS
City: County: Zip Code:68111
Premises Phone Number:402-451-9502
Premises Email address:
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 t
to'/)ttry C<A7v9 liAtirerz
SIG$AT1ØRE REQUIRED BY CORPORA OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
form 103
Manager's informadon must be completed below PLEASE PRINT CLEARW
Last Name:AUSTIN Fi,..N.:CECIL J.
Home Address 5211 NORTHWEST DRIVE
ity:OMAHA DOUGUkS . 68104
County: Zip Code:
402-212-2581
Home Phone Number:
Driver's License Number&State: - - NE
Social Security Number: - -
Date Of Birth - Place of Birth:OMAHA, NE
Email :CECILJAUSTIN@GMAIL.COM
Are you married?If yes,complete,spouse's information(Even if a spousal affidavit has been submitted)
DYES ONO
Spouse's infonnation
Spouses I 2st Name: First Name: MI:
Social Security Number:
Driver's License Number&State:
Date Of Birth: Place Of Birth:
APPLICANT&SPOUSE MUST LIST FOR THE PAST TEN(1a)YEARS
APPLICANT SPOUSE
YEAR 'YEAR YEAR YEAR
CITY&STATE CITY&STATE
FROM TO FROM TO
if
Form 103
MANAGER'S LAST TWO EMPLOYERS 4
YEAR r TELEPHONE
NAME OF EMPLOYER NAME OF SUPERVISOR
FROM TO 0 NITIVIRER
2004 FIRST STUDENT JENNIFEft 402-6724160
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,EyEji.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.
Ei YES El 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 male application for a liquor license in Nebraska or
any other state?
DYES o
IF YES,list the name of the premise(s):
3. Do you,as a manager,qualify under Nebraska Liquor Control Act and do you intend to
supervise,in person,the management of the business?
12DNO
Form 103
4. List the alcohol related training and/or experience(when and where)of the person making application.
41\11.,,CC Training Certificate Issued: Name on Certificate:
Atr'e0
- (410 ;4.6
Date
Applicant Name Name of program(attach copy of course completion certificate)
Orm1/3131Y)
*For list of NLCC Certified Training Programs see
Experience:
Date of
Applicant Name/Job Title EnIployment: Name&Location of Business:
5. Have you enclosed regarding fingerprints?
rflYES EINO
Form 103
•
The above individual(s), being first duly sworn upon oath, deposes and states t ,.uncle d is the
applicant and/or spouse of applicant who makes the above and foregoing appiicatic n(tatI ion 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-I31.01)Nebraska Liquor Control Act.
The undersigned applicant hereby consents to an investigation of his/her biCkiround 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.
("6
Signature of nager Applicant Signature of Spouse
re
ACKNOWLEDGEMENT
State of Nebraska
County of = The foregoing instrument was acknowledged before me this
cl
.- by C c _ ). I
date NAME OF PERSON BEING ACKNOWLEDGED
/
�� Affix Sca 5�19
Notary Public signature RLVME
YG
Enfts
illry2,2418
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
10126i2018 Point-e-Sale Paymerts
YOUR RECEIPT
Nebraska State Patrol- Criminal Identification Division
3800 NW 12th Street, Suite A
Lincoln NE 68521
(402)479-4971
Antonina.Anderson-Trumble@nebraska.gov
Transaction Id: 12603194
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE
Status: APPROVED
Customer Name: MWPHGL F AM 357 Club
•
Check Number: 12450
Account Number: ******
Routing Number: 104000058
nebraska total amount charged USD$30.50
Tootal
Items Location Quantity Order ID
Liquor License 1 22306154 $28.75
Applicant Name: Cecil 3. Austin
Date of Birth:
Last four digits Soc. Security Number:
Total remitted to the Nebraska State Patrol- Criminal Identification Division $28.75
IA
SUBMISSSION OF FINGERPRINTS/
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
Office Llse Only
PHONE: (402)471-2571
FAX: (402)471-2814
Class: License#:
,11
14,
Applicant Name: AUSTIN, CECIL J.
(Corporation.EEC.Partnership or Individual)
Trade Name: 3-5-7 CLUB
(Doing Business As)
) 402 — 451-9502 CECILJAUSTIN@GMAIL.COM
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 w under
"Licensing"tab in "Guidelines/Brochures-. FAILURE TO FILE FINGERPRINT CARDS AND PAY
THE REQUIRED PROCESSING FEE TO THE NEBRASKA STATE PATROL WILL DELAY
THE ISSUANCE OF YOUR LIQUOR LICENSE.
• This completed form MUST be included with your Liquor License Application and/or Manager
Application or changes to: Corporate Officers 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 covered by your payment to insure proper application of payment.
• Fee payment of$28.75 per person must be made directly to the NSP;
It is recommended to make payment through the NSP PayPort online system at wwv ne.golgo/nsp
Or checks made payable to NSP should be mailed directly to the following address:
The Nebraska State Patrol—CID Division
3800 NW 12th 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
PAGE 1
I. Name:AUSTIN CECIL J.
Date of Birth: Last 4 SSN: -
(Please print legibly)
R:
Fingerprints on file with the commission? YES 0
How was payment made to NSP? iiNSP PAYPORT El CASH OCHECK SENT TO NSP Ck
2. Name:
(Please print legibly) ;-
Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES CI
How was payment made to NSP? ONSP PAYPORT 0 CASH OCHECK SENT TO NSP Ck
3. 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#
4. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES E
How was payment made to NSP? ONSP PAYPORT IC ASH OCHECK SENT TO NSP Ck
5. 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 ECASH OCHECK SENT TO NSP Ck
6. 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 CRASH 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 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.
HENRY D. ATKINSON RWDGM
Name(Print): Title:
Sinature: 121sar kltaarnEhi ._ Date: ZS 9/ 024 i
FORM 147
REV JAN 2016
PAGE 2
11=11111111111111111111111h,
MOST WORSHIPFUL PRINCE HALL GRAND LODGE„ F, 8 A. M.
OF NEBRASKA AND ITS JURISDICTION
First ommutucattons
Omaha.Nein aNka—lish 1919 " -Ir
Linvoln, bra3,1o. %JAN.'S 2, 1919 —
Omaliti.Nebraska.Sepiember 6, 1919
pot aged 4 Incoin,\tin aska ,
lugust 13,1919 4`,*
2418 Ames Avenue
Omaha,Nebraska 68111
Office: 1402)471-5177
October 26, 2016
To: Nebraska Liquor Control Commission
301 Centennial Mall South
P.O. Box 95046
Lincoln, NE 68509-5046
RE: New Manager and Officer for 2016-2017
Dear Nebraska Liquor Control Commission:
Please replace names listed on previous Corporation Information with the following:
Atkinson, Henry D. RW Deputy Grand Master(Senior VP)
Austin, Cecil J. • Manager
The paperwork for Cecil J.Austin is attached. Thank you for your assistant in this matter.
Sincerely,
enr . A kinson
Rig t Worshipful Deputy Grand Master
Chairman.Trustee Board
Copy to: Most Worshipful Grand Master
Right Worshipful Senior Grand Warden
STATE OF NEBRASKA
LIQUOR CONTROL COMMISSION
LICENSE NUMBER RETAIL
00 r:11 j
OWNERSHIP C I - INDIVIDUAL
CLASS C ALCOHOLIC LIQUOR ON/OFF SALE P - PARTNERSHIP
4 (INSIDE CORPORATE LIMITS) C - CORPORATION
* * * * * * * * * * * * BOND INFORMATION * * * * * * * * * * *
BOND COMPANY AETNA CAS CO START DATE CANCEL DATE
BOND NUMBER 041S11806 04091975 05151991
BOND AMOUNT FED BASIC PERMIT #
* * * * * * * * * * * * RESTRICTIONS * * * * * * * * * * * * * * *
* * * * * * * * * * * * PREMISES INFORMATION * * * * * * * * * * * * *
TRADE NAME 1 3-5-7 CLUB LICENSE NO.
{ TRADE NAME 2
ADDRESS-1 2414 AMES AVENUE ADDRESS-2 SUITE A
CITY OMAHA COUNTY 01 DOUGLAS ZIP 68111
PHONE 402 451 9502 FAX
MAIL TO:
NAME 3-5-7 CLUB
ADDRESS-1 2414 AMES AVENUE ADDRESS- SUITE A
CITY OMAHA STATE NE ZIP 68111
* * * * * * * * * * * LICENSE DESCRIPTION * * * * * * * * * * *
I -SHAPED AREA APPROX 68' X 106' ON MAIN FLOOR OF TWO STORY BLDG
PLUS NORTH AREA 68' X 49'
* * * * * * * * * * * * 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 Y 04132009 010 10312017
EMAIL:
ACTION DATE DOCUMENT NO. ROLL PAGE ACTION CODE
DEPRESS: ENTER - PROCESS PF11 - INQ NOTES PF12 - HISTORY PAl - RETURN TO MENU
STATE OF NEBRASKA
LIQUOR CONTROL COMMISSION
INQUIRE LICENSE NUMBER of: 1AV) CORPORATION
* * * * * * * * * * * CORPORATION INFORMATION * * * * * * * * * * *
CORP. FTIN NO. 999999999 CORP. PHONE 402 451 9502
CORPORATE NAME MOST WORSHIPFUL PRINCE HALL FAX
ADDRESS 1 GRAND LODGE ADDRESS 2 2414 AMES ST SUITE A
CITY OMAHA ST NE ZIP 68111
RESIDENT AGENT CONWELL, WILLIAM T TOTAL SHARES 99999999.00
CONTROLLING CORPORATION CONTROLLING CORPORATION FTIN NO.
NON PROFIT 999999999
CORPORATION OFFICERS ---- SPOUSE ----
PRESIDENT DOB SSN SHARES DOB SSN
BLAN, TOMMIE L JR - SE° 1
ADDRESS 1 3735 LAUREL AVENUE ADDRESS 2
CITY OMAHA STATE NE ZIP 68111
CORP. OFF. NAME / TITLE DOB SSN SHARES DOB SSN
WHEELER, RODNEY 111111111
, SENIOR VP 11111911
ATKINSON, HENRY D 111111111
2ND VP 11111911
CLOPTON, FREDDIE 111111111
3RD VP 11111911
AUSTIN, CECIL 111111111
TREAS 11111911
MOORE, JAMES E SR 111111111
SEC 11111911
* (FILED AFFIDAVIT OF NONPARTICIPATION)
DEPRESS : ENTER - PROCESS PA1 - RETURN TO MENU
11
Ci Mebraska0„ „ 7.64,
A.vim .11111
►-
1819 Farnam—Suite LC 1 x wvt e t =ri sit j
Omaha, Nebraska 681 83-01 1 2 �;
Buster Brown o� t' -IN
(402) 444-5550 4 = -. _ tv
City Clerk FAX (402) 444-5263 D� . ' `` 44�
94FD FEB0U'-
November 8, 2016
Most Worshipful Prince Flail Grand Lodge Application to appoint Cecil J. Austin
Dba"3-5-7 Club" manager of your present Class"C" Liquor
2414 Ames Avenue, Suite A License location.
Omaha,NE 68111
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 22, 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,
,e5 ,64,0‘26
Buster Brown
City Clerk
BJB:clj
Ci of 0 • ha, 9Vthraskg4�
1819 Farnam —Suite LC 1 z ', it i '=rinl
Omaha, Nebraska 681 83-01 1 2 otri,. �,
Buster Brown (402) 444-5550 Teo
City Clerk FAX (402) 444-5263 04 4
T4D FEB0 '-
November 8, 2016
Cecil J. Austin Application to be appointed manager of the present
5211 Northwest Drive Class "C" Liquor License for Most Worshipful Prince
Omaha, NE 68104 Hail Grand Lodge, dba"3-5-7 Club", 2414 Ames
Avenue, Suite A
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 22, 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
No. /5 /
Most Worshipful Prince Hall Grand Lodge, dba
"3-5-7 Club", 2414 Ames Avenue, Suite A,
requests permission to appoint Cecil J. Austin
manager of their present Class "C" Liquor
License location.
11-22-16;cj
(36
RECEIVED
Presented to Council:
November 22, 2016 - Apptbjed 9 e
Buster Brown
City Clerk