RES 2016-0783 - Appoint Rebecca Rosales manager of Depadua Club E-MAILED TO NLCC U 16\‘11CA.t, -..- K-(-)--
,
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STATE OF NEBRASKA
Pete Ricketts 2016 lily: --t4 ,,,,,, „:„. .0 NEBRASKA LIQUOR CONTROL COMMISSION
Governor Hobert B.Rupe
-- Executive Director
301 Centennial Mall South.5th Floor
MANAGER,KLE t-0VN-:EN DATION PO Box 95046
[1,f'A'3 K Lincoln,Nebraska 68509-5046
Phone(402)471-2571
DATE: May 4th 2016 Fax(402)471-2814 or(402)471-2374
IRS USER 800 833-7352(TM
web address-http//www.lcc ne.govl
TO: Omaha City Clerk E-MAIL: carman.iohrison( cityofornaha.org
MANAGER: Rosales, Rebecca
a75r°k
LICENSEE: Immaculate Conception Church dba DePadua Club at 2701 South Ne Street ti 0
LICENSE#: 1-037539
DUE DATE: June 20th,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 Shannon Nyhoff at
Shannon.nyhoff@nebraska.eov or fax to(402)471-2814,with questions call (402)471-2572.
I
APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS: C- , 3 .
\ IlKliVo
(may attach minutes and/or additional notes)
CLERKS SIGNATURE:DATE:
Janice
Janice M.Wiebusch Rob III II 11 ' I 11 ce Bailey
Commissioner CP 1600008396 irriisstoner
An Equal Opportunity Employer
MANAGER APPLICATION Office Use
rcFrvitL
INSERT-FORM 3c 1
to. 2 2
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH 9EBRAt-+KA
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcemebraska.gov
FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE
PROCESSED
MANAGER MUST:
• Complete all sections of the application. Be sure it is signed by a member or corporate officer,
corporate officer or member must be an individual on file with the Liquor Control Commission
• Fingerprints are required. See form 147 for further information, read form carefully to avoid delays
in processing, 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 or print document from
Secretary of State website 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#1 of the application
Spouse who will participate in the business,the spouse must:
• Sign the application
• Fingerprints are required. See tOrrn 147 for further information, read form carefully to avoid delays
in processing,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 101
REV MAR 2016
Page 1 of 6
MANAGER APPLICATION Office Use :
INSERT-FORM 3c 6 ,C s �'a'
NEBRASKA LIQUOR CONTROL COMMISSION �'
301 CENTENNIAL MALL SOUTH
PO BOX 95046 ra A,SK A av
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 0 i 7 1 E..A ,. ' . , i m :
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 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
1 21 years of age or older
,.. F„tn.. .`� i., ,. k.. '
Name of Corporation/LLC t ( A,,t COn e evilegtattrAY
tea,, a ��.� � t
�t g fin r,• s. �'� � �'"�.e t.ii i &
Liquor License Number: 03 Class Type ,, (ifnew application leave blank)
Premise Trade Name/DBA:' le eX\t,-
Premise Street Address: p 101 i.) t\ 5- -et -
City: 0CAA CA) Cour 0014.,SZip Code: iith
Premise Phone Number: 41D9,'",,. 1
Premise Email address: c'e,(.,. '; c~ ce,hAex- \ cof y \ ,
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.
1-60234
SIGNATURE KWUMED BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
REV MAR 2016
Page 2 of 6
Last Name: )-.,i3 (1'\,se First Name: 'c)N,..60ePt‘Ct) MI:
Home Address: \(Di(3?•s.
`Cei\-\\dIZte:L\ \iek?c
City: \--,C),,Nr'‘C",\TAL) County: sc,),..,w„,) Zip Code: 13g
Home Phone Number: 4D3.-ADLP
Driver's License Number&State:
Social Security Number:
Date Of Birth:_ Place Of Birth: XY\AN )
Email address: QC.-\6.3
- "
[j YES )21--.N"0
MAY 0 2 mi:
First Name:
Spouses Last Name:
Social Security Number:
CONC1,„ OMM
Driver's License Number& State:
Place Of Birth:
Date Of Birth:
• ;„., •-7.-
„„ • -" ." „ -
'5'21111,,r4,1 ; '14
YEAR CITY& STATE YEAR
CITY & STATE YEAR YEAR
FROM TO
FROIVI TO
a014
Form 103
REV MAR 2016
Page 3 of 6
5/11/2016 Enterprise Mail-Re:MANAGERS APPLICATION FOR IMMACULATE CONCEPTION CHURCH
Carman Johnson (CCIk) <carman.johnson@cityofomaha.org>
Re: MANAGER'S APPLICATION FOR IMMACULATE
CONCEPTION CHURCH
1 message
Becky Rosales <beckyreccenter@gmail.com> Wed, May 11 , 2016 at 6:18 PM
To: "Carman Johnson (CCIk)" <carman.johnson@cityofomaha.org>
Hello
Thank you for your patience.
I know I registered on line-didn't know I could print a new card. If not, as soon as it
comes I will mail you a copy.
Drivers license, I think I can do in the morning as my brother is taking my dad for a
haircut.
My new address is 8807 "Q" Street Apt 110B Omaha, NE 68127
Thanks
Becky
On Wed, May 11 , 2016 at 5:20 PM, Carman Johnson (CCIk)
<carman.johnson@cityofomaha.org> wrote:
Good late day Becky
Sorry we have been playing phone tag.
I got your message that you re-register to vote, please send
me a copy of your voter registration.
You will also need to update you Driver license and send
me a copy of that when you have done that.
Reply to this e-mail stating what your new home address is.
https://mail.google.com/mail/u/0/?ui=2&ik=cd387c45eb&view=pt&search=inbox&th=154a21 db2fe9b17e&sim1=154a21 db2fe9b17e 1/2
5/11/2016 Enterprise Mail-Re: MANAGER'S APPLICATION FOR IMMACULATE CONCEPTION CHURCH
Please notify me if you have any questions.
Thanks
Carman Johnson
Liquor Clerk
City of Omaha/City Clerk
1819 Farnam Street
Suite LC-1
Omaha, NE 68183
402-444-5324
402-444-5263 fax
Carman.johnson@cityofamaha.org
https://mail.google.com/mail/u/0/?u i=2&ik=cd387c45eb&view=pt&search=inbox&th=154a21 db2fe9b 17e&sim1=154a21 db2fe9b 17e 2/2
YEAR FROM TO
NAME OF EMPLOYER NAME OF SUPERVISOR
TELEPHONE
)99 LP, fe„, 55Ctift\S‘V‘
198X 1190 ACILWAA Artnte RIUJAurcz,"
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. 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 Jaw,
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.
n YES 1 NO
If yes, please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mmlyyyy) (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?
EYES 321/NO
IF YES,list the name of the premise(s):
Erptt„SFFN
-(4
3. Do you, as a manager,qualify under Nebraska Liquor Control Act -le3 11.0,0gind do you intend to
WI At VPt
supervise, in person, the management of the business?
„gicES 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
Applicant Name (mm/YYYY) Name of program(attach copy of course completion certificate)
*For list of NLCC Certified Training Programs see p-a,, n.g
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
5. Have you enclosed form 1 47 regarding fingerprints?
%YES ONO
,tzeliivED
MAY 0 2 2, 14
4. .4„)14C-4
IJTROL C OP41 MISS
Form 103
REV MAR 2016
Page 5 of 6
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 §53131.0 I 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,
LJ )
ig ture of ager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of C4 r p c The foregoing instrument was acknowledged before me this
Aprilat4L by /` P_be c g-a.. a g a r s
date I NAME OF PERSON BEING ACKNOWLEDGED
Affix Sea!
Notary Public signature 1.4GENERINOTARY-Stte al%rai 4 ALM
*tiara bp.Waxy 14,2011
In compliance with the ADA,this application is available in other format disabilities.
A ten day advance period is required in writing to produce the alternate format,
Form 103
REV MAR 20)6
Page 6 of 6
SUBIIISSSIO►N OF FINGERPRINTS /
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH r
fri
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE: (402)471-2571 Officefi e
FAX: (402)471-2814 i'r ,
Website: www.lce.nebraska.gov Class:__ l k
man. ,1��;ti�
Applicant Name: e,,,\) j9
(Corporation,LLC,Partnership or Individual)
Trade Name: VIV C ,,
(Doing Business As)
019) 392P 9131 \oet:VN,A,c-e. ce4A-e/cONo\r‘o,,A0
Phone Number Contact E-mail'Address
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• See New Application Requirement Guide for listing of Fingerprint Requirements, found on our website
under"Licensing"tab in "Brochures".
• 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.
• Fee payment of$28.75 per person must be made directly to the NSP;
You may submit the 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
• 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.
• 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).
• 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.
Please complete information on the following pages for EACH person fingerprinted.
FORM 147
REV OCT 2015
PAGE 1
1. Name: "Y&U,.;) )
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF'? ❑NSP PAYPORT Or (CHECK SENT TO NSF Ck - ✓>
2. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? ❑NSP PAYPORT Or ❑CHECK SENT TO NSP Ck #
3. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? ❑NSP PAYPORT Or ❑CHECK SENT TO NSP Ck#
4. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSP? ❑NSP PAYPORT Or ❑CHECK SENT TO NSF Ck#
5. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? ❑NSP PAYPORT Or ❑CHECK SENT TO NSP Ck#
6. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? t NSP PAYPORT Or DCHECK SENT TO NSF Ck#
I hereby certify that fees of$28.75 per person have been submitted directly to the Nebraska State Patrol—CID office.
The undersigned certifies on behalf of the Corporation,LLC,Partnership or Licensee that it is understood that a
misrepresentation of fact is cause for rejection of this application or suspension,cancellation or revocation of any license
issued.
Rev John A.Buick F.$.S.P. P
Name(Print): ' Title:
le--
Signature: `; t3 A 0141142,4 Date: la 2 6 2016
FORM 147
REV MAR 2015
PAGE 2
761
IMMACULATE CONCEPTION CHURCH 0 First Nationall3ank
1620 Dodge Street*0010K:41A 68147
BOWLATORIUM
2708 S 24TH ST 27-1-1040
Ofv1AHA,NEBRASKA 68108-1342
4/28/2016
PAY TO THE
ORDER OF Nebraika State Patrol-CID Division $ **28.75
tr*********************************************************** *************************************a• DOLLARS
Twenty-Eight and,75/100
Nebraska State Patrol-CID Division
3800 NW 12th Street
Lincoln, NE 68521
- tql
MEMO AUTHORIZED SIGNATURE
A lication fee
[POO E Lane 10110000 16i: L80 L66 3 311,
IMMACULATE CONCEPTION CHURCH-BOWLAT0f1IUM
7 6 1 :
Nebraska State Patrol-CID Division 4/28/2016
ADMIN SERV:4078 • Taxes& Licenses Application fee-Rebecca Rosales 28.75
r, r.-itJr`r
"' M4418S:ON
Checking#3 Bowling Application fee 28.75
City erasa® 8
� C,rl
1819 Farnam — Suite LC 1 i41 +'�'�
Omaha, Nebraska 681 83-01 1 2 � ii � � '^
Buster Brown 402 444-5550 fy,
City Clerk FAX (402) 444-5263 o44,
4
-4 FEBRV�
May 24, 2016
Immaculate Conception Church Application to appoint Rebecca Rosales
Dba"DePadua Club" manager of your present Class "I" Liquor
2708 South 24th Street License location at 2701 South 25th Street
Omaha, NE 68105
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 7, 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
CiiqCity of Omaha Nebraska OMAHA N�
z rid 3
1819 Farnam — Suite LC 1 W �. '�� Mit
Omaha, Nebraska 68183-0112 6552 .�'�'„ liO
cso
Buster Brown (402) 444-5550 d
.�. �� ry.
City Clerk FAX (402) 444-5263 p
9TFD FEBR�A
May 24, 2016
Rebecca Rosales Application to be appointed manager of the present
8807 "Q" Street Class "I" Liquor License location for Immaculate
Apt#110B Conception Church, dba"DePadua Club", 2701
Omaha, NE 68127 South 25th 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 7, 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,
41.4e-1
Buster Brown
City Clerk
BJB:clj
No.
Immaculate Conception Church, dba "DePadua
Club", 2701 South 25th Street, requests
permission to appoint Rebecca Rosales
manager of their present Class "I" Liquor
License location.
06-07-16;cjjo
RECEIVED
Presented to Council:
June 7, 2016 - Approved o—C
Buster Brown
City Clerk