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RES 2016-1549 - Appoint Brian D Hexsel manager of Chipotle Mexican Grill #450 E-MAILED TO NLCC ,t ;�gE ST44`')t r v _ ,', STATE OF NEBRASKA l' > Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION m 0' 41 11 %arc Hobert B. Rope r,. Governor ,r r r,W , a = i ul! ` -, ., , rs Executive Director n\r'8 R�g6� V ' . 301 Centennial Mall South,5th Floor MANAGER RECOMMENDATION P.O.Box 95046 Lincoln,Nebraska 68509-5046 Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 DATE: October 17, 2016 ` Y, TRS USER 800 833-7352(TI'Y) TO: City Clerk of OMAHA E-MAIL: carman.Johnson@cityofomaha.org,veb address:http://www.lcc.ne.gov/ MANAGER: Brian D Hexsel LICENSEE: Chipotle Mexican Grill Inc LICENSE#: 1-062823 DUE DATE: December 1, 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 tracv•burmeister@nebraska.gov or fax to (402)471-2814,with questions call (402)471-2572. Y APPROVED NO LOCAL RECOMMENDATION DENIED COMMENTS: ((12—D it ic5g U ,h 1 2 ,C S/' ��' (May attach minutes and/or additional notes) 4 CLERKS SIGNATURE: —_\ --z.,‘..._ DATE: �f / ir- 1600020047 Janice M.Wiebusch Robert Batt Bruce Bailey Commissioner Chairman Commissioner An Equal Opportunity Employer MANAGER APPLICATION Office Use 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.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 ✓ 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 L�9J5?°7�°1°�°11Vf�fli PC iiifi(9)0. Chipotle Mexican Grill,Inc. Name of Corporation/LLC: Liquor License Number: 062823 Class Type I (if new application leave blank) Premise Trade Name/DBA:Chipotle Mexican Grill#450 Premise Street Address:3605 N. 147 Street, Suite 111 City: Omaha County: Douglas Zip Code: 68164 Premise Phone Number: 402-498-3633 Premise Email address:licensing(uchipotic.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. CA-evt'i Ms, Co-C O e Ape.r eA a r�. 9 0 : .P- SICl'��T T. ii r.@1..4) Igo . s. � v' "EH�� fa � `�. �� `ai,v :1 a.w. (Faxed signatures are acceptable) Form 103 REV MAR2016 Page 2 of 6 1��_:__ 1t2 _J �.� :_.,.�• laJ' . .1 �y'1 ^�J�sf?!�I �'t_� 4° �° ,> Hexsel First Name:Brian MI:D Last Name: - Home Address:5211 Seward St. city:Omaha County:Douglas Zip Code:6$104 Home Phone Number:832.372.3899 - Driver's License Number&State:_ N E Social Security Number: Date Of Birth: Place Of Birth:Humble, TX Email address:bhexsel@chipotle.com t� .� r r ,l lq �r al 1 10 �s A Irc�Sis;:fin 6 1�._ y�S [ V.� a a y-1r' �-tap',+.v . I�i kya r& ��f•) ,,!�,:�,�Q._.4 •.��r e..`�R•=,f,�'.�'�?��:.�e�. �.���?n..._� �_X91�_ _J} ❑'YES CI NO Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number&State: Date Of Birth: Place Of Birth: IT :Itl clZ]iir 1i,C,)�(��� � Y ( i` �7f>1� ,� R��` gn �f �a/ Y Yi °7 6 ' }} i (6 .x... �7...��-'s..°�'.�-. ... ._.-.��....�'2�� A11,,-i•: :_... '1�>,ia. ��5� :_.� .,..�"�s :�' _.._.... r"R� ���aR{A�I � 9*(9 (fir• Lit.:':L_R�r���j iLl dAOaya.l���> CITY&STATE FROM 'YEAR CITY&STATE FROM YEAR O Newport Beach, CA 2009 2014 • Denver, CO 2014 2016 Omaha, NE 2016 Present Form 103 REV MAR 2016 Page 3 of 6 YEAR TELEPHONE FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR NUMBER 2010 Present Chipotle Mexican Grill Alfredo Ponce 720.296.5414 2008 2010 FreeBirds Payman Kanya - I. 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,SWR been convicted of or plead guilty to any charge. Charge means mix 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,includ'I'ti'reto `oils'. 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 X 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) Charge 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES ONO IF YES,list the name of the premise(s): 3. Do you, as a manager,qualify under Nebraska Liquor Control Act 1'453-131.01) and do you intend to supervise,in person,the management of the business? DYES ONO Form 103 REV MAR 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: Date Name of program(attach copy of course completion certificate) Applicant Name (m�YYYY) _ *For list of NLCC Certified Training Programs see training Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: gr:r.on - I,1 _2olo-4 It C -N> . 'M ,tA• Gi \ 5. Have you enclosed form 147 regarding fingerprints? DYES ONO Form 103 REV MAR 2016 Page 5 of 6 t4 1) !,\ [ N\ a r n j �f S e� n"dE C,oy, t}';;P§(AO (Cg 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:On 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. ignature of Manaplicant Signature of Spouse ACKNOWLEDGEMENT State oftcetwdo County of ,YWCY The foregoing instrument was acknowledged before me this n \IOW4 by O V1 Mt)CStt date NAME OF PERSON BEING ACKNOWLEDGED Affix Seal AtEa ELAN CHRISTyWSEN Notary Public signature NOTARY PUBUC-STATE OF COLORADO idyl ��A016�137?1 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. Fonn 103 REV MAR 2016 Page 6 of 6 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 4se Only PHONE: (402)471-2571 FAX: (402)471-2814 Class: License#: \\'ebsite: tav\v,.lcc.nebraska.1.1o. Applicant Name: Chipotle Mexican Grill, Inc. (Corporation,LLC,Partnership or Individual) Trade Name: Chipotle Mexican Grill#450 (Doing Business As) (402) 498 — 3633 Iicensing©chipotle.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»cb,ite 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 www.ne.gov/go/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 14:" � 1. Name:Brian Hexsel Date of Birth: Last 4 SSN: (Please print legibly) Fingerprints to be taken Thursday, 10/20 Fingerprints on file with the commission? YES How was payment made to NSP? NSP PAYPORT OCASH ❑CHECK SENT TO NSP Ck# 2. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES 0 How was payment made to NSP? ❑NSP PAYPORT OCASH DCHECK 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? DNSP PAYPORT OCASH DCHECK 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? DNSP PAYPORT OCASH 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? DNSP PAYPORT DCASH ❑CHECK 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? DNSP PAYPORT OCASH DCHECK SENT TO NSP Ck# I hereby certify that fees of S28.75 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. Name(Print): Brian Hexsel Title: Manager Signature: Date: DI(7 RIP FORM 147 REV JAN 2016 PAGE 2 of 0 I I Nebraska OF -,F WilVr' 1819 Farnam - Suite LC 1 i44, gN. Omaha, Nebraska 68183-0112 n ,,.r/ 1 00 Buster Brown (402) 444-5550 � .r City Clerk FAX (402) 444-5263 o '"�gory 4TED FE13W October 25, 2016 Chipole Mexican Grill, Inc. Application to appoint Brian D. Hexsel Dba"Chipotle Mexican Grill #450" manager of your present Class ""I" Liquor 3605 North 147th Street, Suite 111 License location Omaha,NE 68116 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 8, 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, rfb' Buster Brown City Clerk BJB:clj A, ®N►�.HELAi, r 0 Li of t y fI ha, Nebraska 0 ci,Airimp.or..41,14, :1,,,t,, 1819 Farnam - Suite LC 1 Weez / 41 2t 1 Omaha, Nebraska 68183-0112 �. „,rZc i ,,� uster Brown (402) 444-5550 "�,` �= �; �,, City Clerk FAX (402) 444-5263 o4R i" RFD FEEat October 25, 2016 Brian D. Hexsel Application to be appointed manager of the 5211 Seward Street present Class"I" Liquor Licenses for Chipotle Omaha,NE 68104 Mexican Grill, Inc. (See attached list) 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 8, 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, r 4/41.e Buster Brown City Clerk BJB:clj CHIPOTLE MEXICAN GRILL, INC 3605 NORTH 147TH ST, SUITE 111 DBA CHIPOTLE MEXICAN GRILL #450 CHIPOTLE MEXICAN GRILL, INC 201 SOUTH 72ND STREET DBA CHIPOTLE MEXICAN GRILL #612 CHIPOTLE MEXICAN GRILL, INC 2717 SOUTH 177TH STREET DBA CHIPOTLE MEXICAN GRILL#666 CHIPOTLE MEXICAN GRILL, INC 13203 WEST CENTER ROAD DBA CHIPOTLE MEXICAN GRILL #707 21,Zig' No. Chipotle Mexican Gill, Inc., dba "Chipotle Mexican Grill #450", 3605 North 147th Street, Suite 111, requests permission to appoint Brian D. Hexsel manager of their present Class "I" Liquor License location. 11-08-16;cj RECEIVED Presented to Council: November 8, 2016 - Approved a Buster Brown City Clerk