RES 2016-0903 - Appoint Jeffrey Elafros manager of Buffalo Wild Wings 39 E-MAILED TO NLCC
s "i
- �} * r \° i "' STATE OF NEBRASKA
w .w a Pete Ricketts L i C NEBRASKA LIQUOR CoPmtoL COMMISSION
�' A Governor Hobert B.Rupe
Executive Director
_- ' c, r- 301 Centennial Mall South,5th Floor
MANAGER RECOMMEND&ION PO.Box 95046
Lincoln,Nebraska 68509-5046
Phone(402)471-2571
DATE: May 24th,2016 Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(11y1`)
web address.http://www.lcc.ne:gov/
TO: Omaha City Clerk E-MAIL: carman.iohnsonc citvofomaha.ora
MANAGER: Jeffrey Elafros
LICENSEE: Blazing Wings Inc.
LICENSE#: 1-047209
DUE DATE: July 11, 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.burmeisterttnebraskaiov or fax to(402)471-2814,with questions call(402)471-2572.
APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS: .6_01 /O ,cisse
(may attach minutes and/or additional notes)
CLERKS SIGNATURE:
DATE: ,/p
02,90/aev."--
1600010119
Janice M.Wiebuach Robert Batt Bruce Bailey
Commissioner Chairman Commissioner
An Equal Opportunity Employer
MANAGER APPLICATION Office Use
INSERT-FORM 3c
RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
N E RMAASYK2A5 LIQUOR°1
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX (402)471-2814 CONTROL ""
..u.1%4MISSION
Website:www.lec.nebraska.gov
Manager must:
• Complete all sections of the application. Be sure it is signed by a corporate officer,corporate officer
must be an individual on file with the Liquor Control Commission
• Fingerprints are required. See Form 147 for further information, this form MUST be included with
your application.
• Provide a copy of one of the following: US birth certificate, naturalization papers or current US
passport(even if you have provided this before)
• Be a registered voter in the State of Nebraska, include a copy of voter card with application
Spouse who will not participate in the business,spouse must:
• Complete the Spousal Affidavit of Non Participation Insert (must be notarized). The non-
participating spouse completes the top half: the manager completes the bottom half Be sure to
complete both halves of this form.
• Need not answer question 41 of the application
Spouse who Ell participate in the business,the spouse must:
• Sign the application
• Fingerprints are required. See Form 147 for further information, this form MUST be included with
your application.
• Provide a copy of one of the following: birth certificate,naturalization papers or current US passport
(even if you have provided this before)
• Be a registered voter in the state of Nebraska. include a copy of voter card with application
• Spousal Affidavit of Non Participation Insert not required
Form 103
REV JUNE 2015
Page 1 of 6
MANAGER APPLICATION Office Use
INSERT-FORM 3c E EVE
NEBRASKA LIQUOR CONTROL COMMISSION 2
301 CENTENNIAL MALL SOUTH
PO BOX 9504b NEBRASKA11Qt}{ R
LINCt7LN,NE 68509-5045 CON RO COM"1V4I Slt t'�
PHONE:(402)471-2571
FAX:(402)471-2814
Website:wwwIcc.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 in the State of Nebraska
✓ Fingerprinted. See Form 147 for further information,this form MUST be included with your
application.
✓ 21 years of age or older
Corporation/LLC inform ipn _ _ - u ... .,„„..,w .. . -.
Name of Corporation/LLC: $1 tik Z 1 n ;n 47 Sti C,
Premise information ,..„'.. a . ` 0., 1., ..,r.. a:,.a..,,:. , ....z A
Liquor License Number _�,. )� 4.Ar` , Class Type 1 (if new application leave blank)
Premise Trade Name/DBA: t)t,..Y !0 inl i t W l(9
Premise Street Address: 2 o iv G $ .[e �-- !
City: 0 O.)1 01 County: Do ki+- I Lt. 5 Zip Code: 62 8 1) !
(Jo?)
Premise Phone Number: - L/ 3 9 ti 6 4-1
Email address: 31 (:).) '0 k.A l0 w 1 to\ iit S . LOr'1
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. Click on this link to see authorized individuals.
ilttp: :wwkli,1cc.ne.ito/license scarch/Iicsearrh.e i
lam ;
R
(Faxed signatures are acceptable)
Porto 103
REV TUNE 2015
Page 2 of 6
anng+er's rir ri ion mash corn
Last Name: 5 k {I S First Name: j-e-if f'c MI:
Home Address(include PO Box if applicable): 5(128 iv I i Ci)-c/e..
City: } '(1„11x County: 1911%."Cj Zip Code: �AI t
I
Home Phone Number: (i02) lt7 q — 3 729 Business Phone Number:
Social Security Number: Drivers License Number& State:
Date Of Birth: Place Of Birth: t b( Sfll
Email address: 31 6) IO Lv M wv.`,.corip
Are you married?Jryes,'comPlete ':us`ec s in o n taitO l %ven if a s ii 3R -reed 'ii fd
❑ YES M NO
Spause' j�` r w � ,�y .E py v � aka '"
... `, ` x wad. 'Pt
Spouses Last Name: First Name: MI:
Social Security Number: Drivers License Number& State:
Date Of Birth: Place Of Birth:
APPLICANT & SPOUSE MUST LIST RESIDENCY(S)FOR THE PAST TEN (10)YEARS
APPLICANT SPOUSE
YEAR YEAR YEAR YEAR YEAR
CITY&STATE CITY & STATE
FROM TO FROM TO
it
RECEIVED
MAY 2 5 2016
NESRASIA LIQUOR
I
CONTROL COMMISSION Fay 103
REV SUNE 2015
Page 3 of 6
ti
YEAR TELEPHONE
NAME OF EMPLOYER NAME OF SUPERVISOR
FROM TO NUMBER
Zo 11 Zoe) r;e, Grit O Z 3,79
Zail 20 Olof tcD
ai [112) 346-8075
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 'mute of the charge. where the charge occurred and the year and month of the
conviction or plea. Also list any charges pending at the time of this application. If more than one party, please list
charges by each individual's name.
�) YES 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
?. 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):
4
3. Do you, as a manager, qualify under Nebraska Liquor Control Act (§53-131.01)and do you intend to
supervise,in person,the management of the business? RECEIVED
EYES flNO
MAY 2 5 2816
NEBRASKA LIQUOR
CONTROL COMMISSION
Form 103
REV TUNE 20I5
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: /1\I/1 Name on Certificate:
f
Date
Applicant Name (1111/1/YYYY) Name of program(attach copy of course completion certificate)
I
*For list of NLCC Certified Training Programs see 1 \\,k kl. Ile vo‘ tram trunnlo hi f ni
Experience:
Applicant Name/Job Title Date ofName&Location of Business:
Employment:
,..,.-
5. Have you enclosed Form 147 regarding fingerprints?
ES ONO
RECEIVED
MAY 2 5 2016
.,.
C ONNETeRROALSCOMMISSION
LIQUOR
Form 103
REV JUNE 2015
Page 5 of 6
3
The above individual(s). being first duly sworn upon oath, deposes and states that theundersigned 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.
Si re of Manager Applicant Signature of Spouse
A
ACKNOWLEDGEMENT
State of Nebraska
County of Do tA.tot S The foregoing instrument was acknowledged before me this
5-1/-2.0 b by E f 4/ E1'3 E(,$
dale name of person acknowledged
' ''''2./1`4141/4.;/-fi,
J
Notary Public signature „Ws
.,.,. r KOALAS
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.
RECEIVED
MAY 252011
NEBRASKA LIQUOR
CONTROL COMMISSION Form 103
REV JUNE 2015
Page 6 of 6
SUBMISSSION OF FINGERPRINTS / CIVD
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION MAY 2 5 2216
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRASKA LIQUOR
LINCOLN,NE 68509-5046 CONTROL COMMISSION
PHONE: (402)471-2571 Office Use Only
FAX: (402)471-2814
Website: wwwice.nebraskagov Class: License#:
Applicant Name: Ir4
(Corporation,LLC,Partnership or indi 1)
Trade Name: 1?)1/4.5-Rcs, tij
(Doing Business As)
0q 5977
licse rt96, WWI
Phone Number Contact E a I 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". FAIXURA TO FILE FINGERPRINT CARDS AND PAY
THE REOUIREP PROCESSING EEE TO THE NEBRASKA STATE PATROL WILL DELAY
THE IMUANCE OF YOUR LWOR 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 conmkte information on the following pages for EACH person fingerprinted.
FORM 147
REV MAR 2016
PAGE 1
E.
i. Namocse-k--c-cle,) . (k ccr--- Date of Birth: ast 4 SSN: _
(Pleas print legibly) ( 1
Fingerprints on file ' the commission? YES Li
How was payment made to NSP? ONSP PAYPORT OCASH El 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? ONSP PAYPORT Li CASH OCHECK SENT TO NSP Ck#
3. 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 OCASH OCHECK SENT TO NSP Ck#
&EC
4. Name: EItirtz.a.,
(Please print legibly) 4•-,ti
Date of Birth: Last 4 SSN:
Fingerprints on file with the commission? YES 0
• "44111)How was payment made to NSP? O 0 NSP PAYPORT OCASH CHE '
5. Name: "-'47/SSio
Ai
(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 Li 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? ENSP PAYPORT DCASH 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.
..
Name(Print): A) C. -1 \- r S-- ..9 C.iAt Tit4ce.Prek
04."
Signatur i Date:
e: , .5A1
s\ao tko
FORM 147
REV JAN 2016
PAGE 2
Point-of-Sale Payments Page 1 of 2
PA Fli •
•
NEBR .S . . ,G \'
YOUR RECEIPT
Nebraska State Patrol-Criminal Identification Division RECEIVEri
3800 NW 12th Street, Suite A
Lincoln NE 68521
(402)479-4971 MAY
Antonina.Anderson-Trumble@nebraska.gov )
Transaction Id: 9989798 NEAsie
LIQUOR
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE CONTROL- C ON
Customer Name: Allison Kulas
Credit Card Number: **** **** ****
nebraska total amount charged $29.47
Items Location Quantity Order ID Total
Amount
Liquor License 1 20589184 $28.75
Applicant Name: 3eff Elafros
Date of Birth:
Last four digits Soc. Security Number:
Total remitted to the Nebraska State Patrol-Criminal Identification Division $28.75
hops://otc.cdc.nicusa.comlPublicReceipt.aspx?src=csh 5/4/2016
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MA Y 5 Z0/6
May 23, 2016 NEBRAS
CONr LIQUo
ROL, OMMrssj
Via Fe dEx
Nebraska Liquor Control Commission
301 Centennial Mall South
PO Box 95046
Lincoln, NE 68509-5046
RE: Blazin Wings, Inc. dlb/a Buffalo Wild Wings#39
205 N. 76th Street
Omaha, NE 68114
Manager Registration Packet for Jeffrey Elafros
To Whom It May Concern:
Enclosed please find the following items necessary to register Jeffrey Elafros as the
Manager for the restaurant listed above:
• Manager Application- Form 3c;
• Copy of Birth Certificate;
• Copy of Driver's License
• Voter registration; and
• Submission of Fingerprints/Payment of Fees to NSP-CID.
If you have any questions or require additional information, please do not hesitate to
contact me.
• Sincerely,
BUFFALO WILD WINGS, INC.
Allison Kulas
Licensing Coordinator
(952) 479-2496
oMAA, N�
City ofOmaha, WJthrasIa � ,4
1819 Farnam — Suite LC 1 it,<`J -*'
Omaha, Nebraska 681 83-01 1 2 n�L,i1. '�+
Buster Brown (402) 444-5550 e,.
City Clerk FAX (402) 444-5263 p'�e
FEB 4�
TFD R13�
June 7, 2016
Blazin Wings, Inc. Application to appoint Jeffrey Elafros
Dba"Buffalo Wild Wings 39" manager of your present Class "I" Liquor
205 North 76th Street License location
Omaha,NE 68114
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 June 21, 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,
44Cd/‘)*°a*
Buster Brown
City Clerk
BJB:clj
City of Omalui, Nebraska )0t
1819 Farnam — Suite LC 1 z l'ir414*
Omaha, Nebraska 68183-0112 tial2
Buster Brown (402) 444-5550 ti•
City Clerk FAX (402) 444-5263 O41'FD FEBO'1-
June 7, 2014
Jeffrey Elafros Application to be appointed manager of
3628 North 92nd Circle present Class "I" Liquor License for
Omaha,NE 68134 Blazin Wings, Inc., dba"Buffalo Wild
Wings 39", 205 North 76th Street
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 June 21, 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,
*te 444 00.40
Buster Brown
City Clerk
BJB:clj
_6
5-
No. 9i�3
Blazin Wings, Inc., dba "Buffalo Wild Wings
39", 205 North 76th Street, requests permission
to appoint Jeffrey Elafros manager of their
present Class "I" Liquor License location.
06-21-16;cj I
RECEIVED
Presented to Council:
June 21, 2016 - Approved 7-o
Buster Brown
City Clerk