RES 2016-1552 - Appoint Brian D Hexsel manager of Chipotle Mexican Grill #707 E-MAILED TO NLCC t—C\ -1 `e
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STATE OF
'; Pete Ricketts NEBAASI�A
NEBRASKA LIQUOR CONTROL COMMISSION
4 Governor
!r,Rctt A ,�61 t L i 1 r. I Hobert B.Rupe
Executive Director
301 Centennial Mall South,5th Floor
MANAGER RECOMMENDATION P.O.sox 95046
Lincoln,Nebraska 68509-5046
DATE: October 17, 2016 Phone(402)471 2571
TO: Fax(402)471-2814 or(402)471-2374
City Clerk of OMAHA E-MAIL:carman.johnson@cityofomaha.orgw TRS USER 800 833-7352(TTY)
eb address:http://www lcc.ne.gov/
MANAGER: Brian D Hexsel
LICENSEE: Chipotle Mexican Grill Inc
LICENSE#: 1-069228
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 oar or fax to (402)471-2814,with questions call (402)471-2572.
APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS: V(g1A C/
6
(May attach minutes and/or additional notes)
CLERKS SIGNATURE:
DATE:
l600020045
Janice M.Wiebusch
Commissioner Robert Batt
Chairman Bruce Bailey
Commissioner
An Equal Opportunity Employer
W.
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-`, MANAGER APPLICATION
INSERT-FORM 3c Office use
£p NEBRASKA LIQUOR CONTROL COMNIISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.nebraska.gov
MUST BE:
✓ Citizen of the United States. Include copy of US birth certificate,naturalization inner or current US
ass rt
✓ Nebraska resident. Include copy of voter registration card orrint out document from Secretary of
51/kackaik
✓ Fingerprinted. See form 147 for further information,read form carefully to avoid delays in
processing,this form MUST be included with your application
V 21 years of age or older
Chipotle Mexican Grill,Inc.
Name of Corporation/LLC:
Liquor License Number: 069228 I
Class Type (If new application leave blank)
Premise Trade Name/DBA;Chipotle Mexican Grill#707
Premise Street Address: 13203 W. Center Road
City: Omaha Douglas
�
Coun ,: g
Zip Code:b8144
Premise Phone Number: 402-697-4903
Premise Email address:licensing@chipotle.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.
" . . _ -MD
SZGNA b $ bpi►O Il5 GO
(Faxed signatures are acceptable)
Form 103
REV MAR 2016
Page 2 of 6
..�,, �s.�:,�...!2 ",,a,�.[I'�I��1 a �1 1 ?•'-�('$t 0'����"�� aC [' {n""a
Last Name: Hexsel Brian .D
First Name: MI.
Home Address:5211 Seward St.
Omaha
Cif'' county:Douglas Zip Code:68104
Home Phone Number:
832.372'3899
Driver's License Number&State: NE
Social Security Number:
Date Of Birth: — ——— PIace Of Birth:Humble, TX
Email address:bhexsel@chipotle.corn
zELNd-
❑YES NO
Spouses Last Name: First Name:
MI:
Social Security Number:
Driver's License Number&State:
Date Of Birth: Place Of Birth:
Vc
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YER
CITY& STATE ` CITY& STATE �'EYEAR
FROM TO FROM TO
Newport Beach, CA 2009 2014
Denver, CO 2014 2016
Omaha, NE 2016 Present
Form 103
REV MAR 2016
Page 3 of 6
FROM A T TELEPHONE
O NAME OF EMPLOYER NAME OF SUPERVISOR
r" 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, .'31; been convicted of or plead guilty to any charge.
Charge means my 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,mcl fde ti d i 1 s. 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
• (mm/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 FNO
IF YES,list the name of the premise(s):
3. Do you, as a manager, qualify under Nebraska Liquor Control Act(03-131.01)and do you intend to
supervise,in person,the management of the business?
DYES ONO
Form 103
REV MAR 2016
Page 4 of 6
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4. List the alcohol related training and/or experience(when and where)of the person making application.
'dk
a ' *NLCC Training Certificate Issued: Name on Certificate:
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Applicant Name Date Name of program(attach copy of course completion certificate)
4 i (mMIYYYY)
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is
114)
*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date ofName&Location of Business:
Employment:
66 + - �Lw � Zino— L't C lo\-, ' taA C5-0l\
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^
5. Have you enclosed form 147 regarding fingerprints?
t
,` EYES ONO
Form 103
REV MAR 2016
Page 5 of 6
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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
sP.
penalties provided by law. (Sec§53-131:01)Nebraska Liquor Control Act.
t
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
Si spouse may have against the Nebraska Liquor Control Commission and any other individual disclosing or
Al
44 releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly or
tot
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
t fraudulent.
Y
T
, -_ ignature of Manairet4pplicant Signature of Spouse
is
ACKNOWLEDGEMENT
�. State of �b
,.
4 County of CX,Y1VCY The foregoing instrument was acknowledged before me this
k! 1,o�V\\Ukk.� bY �Q,V : t ct\
date NAME OF PERSON BEING ACKNOWLEDGED
4; ....--7 ... [..........,.........j
Affix Seal
TA �
Notary Public signature NOTARY PUBLIC-STATEOFOCO OAADO
My fdendedon 120154013771
ExplreaApttl 8,2018
a
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.
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Form 103
,;;', REV MAR 2016
Page 6 of 6
eA.
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 Use Only
PHONE:(402)471-2571
FAX:(402)471-2814
11 ebsite: N1NN .lec.nebraska.go Class: License#:
Applicant Name: Chipotle Mexican Grill,Inc.
(Corporation,LLC,Partnership or Individual)
Trade Name: Chipotle Mexican Grill#707
(Doing Business As)
(402) 697 — 4903 licensing@chlpotle.com
Phone Number Contact E-mail Address
h;.
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• See Application Requirement Guide for listing of Fingerprint Requirements,found on our N‘chtiite 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 NSF;
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/t;o/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
cxyaj
{x+y
ha
Brian Hexsel
l. Name: Date of Birth: Last 4 SSN:
fr
(Please print legibly)
Fingerprints to be taken Thursday, 10/20
z . Fingerprints on file with the commission? YES El
How was payment made to NSP? NSP PAYPORT ❑CASH OCHECK 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? ONSP PAYPORT ❑CASH OCHECK SENT TO NSP Ck#
3. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES ❑
i, How was payment made to NSP? ONSP PAYPORT ❑CASH OCHECK SENT TO NSP Ck#
A
4. Name:
(Please print legibly)
''4ry-x Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES 0
How was payment made to NSP? ONSP PAYPORT ❑CASH OCHECK SENT TO NSP Ck#
5. Name:
(Please print legibly)
r``; Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES 0
How was payment made to NSP? ONSP PAYPORT ❑CASH 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 0 CASH 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 of this application or suspension,cancellation or revocation of
� P rejectionPP P
any license issued.
Brian Hexsel Title: Manager
Name(Print): 9
44.
Signature: Date: 1011/110
FORM 147
is REV JAN 2016
PAGE 2
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6Lay o . . ? • 1 Nebraska
1819 Farnam — Suite L.0 1 z„ap , .1 .k
n �lr '+Omaha, Nebraska 681 83-01 1 2 ,„_ v � „� ,� �
Buster Brown (402) 444-5550 '�,, iv
City Clerk FAX (402) 444-5263 04, 4.
9TEDFOIL- ..
October 25, 2016
Chipole Mexican Grill, Inc. Application to appoint Brian D. Hexsel
Dba"Chipotle Mexican Grill #707" manager of your present Class""I"Liquor
13203 West Center Road License location
Omaha, NE 68144
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.
Sincerel yours,
e‘y
di 9°' 4196vasio<
Buster Brown
City Clerk
BJB:clj
City of 0 • ha, Nebraska
04,E ��'� �, �'�.,
1819 Farnam — Suite LC 1 Tt` r .D� titt
Omaha, Nebraska 681 83-01 1 2 nVy.r'1A641-1
Buster Brown
(402) 444-5550 '�,�
City Clerk FAX (402) 444-5263 0�
4ry
9TEDFE1
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,
,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
No. / 5k
Chipotle Mexican Gill, Inc., dba "Chipotle
Mexican Grill #707", 13203 West Center Road,
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 7-c,
Buster Brown
City Clerk