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RES 2016-0422 - Appoint Bethany E Baratta manager of Fountain West E-MAILED TO NLCC / — 7—/ , •�:; STATE OF NEBRASKA yiif ur ar Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION , '1 Governor Hobert B. Rope �P Executive Director h:"EkCH F`1t,' 301 Centennial Mall South,5th Floor MANAGER RECOMMENDATION P.O.Box 95046 Lincoln, Nebraska 68509-5046 Phone(402i 471-2571 DATE: February 26,2016 Fax(402)471 2814 or(402)471-2374 TRS USER 800 833-7352(TTY) eb address:http://wwcc lcc.ne.goe/ TO: Omaha City Clerk E-MAIL: carman.johnsonCc�cityofoma` a.org n" cr., - MANAGER: Baratta, Bethany E LICENSEE: DRC Williams Inc.dba The Fountains West at 4714 N. 120th Street --. f .—iti • ,_ i/+ -,dye c.'y LICENSE#: I-#097121 '`' :I ' r.. I�1 tr, DUE DATE: April 14th,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.gov or fax to (402)471-2814,with questions call (402)471-2572. XAPPROVED C CjQ46 ��� A 67 5 /'6 NO LOCAL RECOMMENDATION DENIED COMMENTS: (may attach minutes and/or additional notes) CLERKS SIGNATURE: DATE: 7 c01� Janice M.Wiebusch Robert Batt Bruce Bailey Commissioner Chairman Commissioner An Equal Opporttmity 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 x 5 a. :; FAX:(402)471 2814 Website:www.1ec.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#1 of the application Spouse who will 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 NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH 0 ; 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 cony 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 Name of Corporation/LLC: C vi `\`t CA S Iv Liquor License Number: 0 C1 —1 I a I Class Type J (if new application leave blank) Premise Trade NamefDBA: —1\'`1 e Y"'O6'n rl a? S Premise Street Address: 41 - 4 0 ` YY City: 0 v'vv CA \1 CA County: 1:./O LAT C^`> Zip Code: l9 y Premise Phone Number: 4 G -- c6c2,4 Email address: '--\`c 4 4 vv1 i V\v C, ( 0*"v 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. http://www.lcc.ne.gov/license search/licsearch.cgi K3-4-2016 SIG ATURE REQUIRED BY CORPORATE OFFICER/MANAGING MEMBER (Faxed signatures are acceptable) 1600004054 Form 103 REV DUNE 2015 Page 2 of 6 MANAGER APPLICATION office Use INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 0 4 , 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 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 Name of Corporation/LLC: C ,\v, c I.VZ�-- Liquor License Number: C ei. Class Type (if new application leave blank) Premise Trade Name/DBA: �11 € \A, t'.S Premise Street Address: 41 t 0 tin e- ; City: C J\r\A CA b C1 County: D o uc i 1 C^5 Zip Code: (.9 l sty i Premise Phone Number: 6r O — 9A4 1 1 "1 Email address: �`ol-f- Yv1 v Av't( c C.©(v 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. http://www.Icc.ne.Rov/license search/licsearch.cei SIGNATURE REQUIRED BY CORPORATE OFFICER/MANAGING MEMBER (Faxed signatures are acceptable) Form 103 REV JUNE 2015 Page 2 of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: CA.v"--c" First Name: n- ,- -B Home Address(include PO Box if applicable): 3(--/ e.n flAS LA rv...k.c., City: k-CA \ ° County: (->Ck e-1-- Zip Code: Home Phone Number: -A 0%) - I S -1 1 Business Phone Number: 40d- ,4- Social Security Number: Drivers License Number&State: , „ „, - Date Of Birth: Place Of Birth: 0 vNA h Email address:address: +\ C v-t 61) \AA e,vvi v.( cc• . owl Are you married?If yes,complete vouse's information(Even if a spousal affidavit has been submitted) YES NO „ ! Spouse's information Spouses Last Name: First Name: MI: Social Security Number: Drivers License Number& Date Of Birth: Place Of Birth: APri4e4ag MUST LIST RESIDENCE(S)fOR TIlEPAST TEN(10)YEARS YEAR YEAR YEAR CITY& STATE CITY&STATE YEAR FROM TO FROM TO JL Form 103 REV JUNE 2015 Page 3 of 6 • . liAlkiAGEWSUST TWO EMPLOYERS YEAR TELEPHONE NAME OF EMPLOYER NAME OF SUPERVISOR FROM TO NUMBER ott.) `:- L/\0‘A)G--t." Povi-rtC/V--- L,s1-oil•C 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 nature 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 fij 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 Be-0'1p nt-is 0S/aco°1Po1JEixtcyvku(Y.Z; ,i-evs, 07v 025 A01 OmaVi9tiME tA); tkfo v"e C tkriS cc,,A kz.k Cjt V't k-af pea 2. Have you or your spouse ever been approved or made application for a,liquor license in Nebraska or any other state? OYES 3KNO IF YES,list the name of the premise(s): 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? YES nNO Form 103 REV JUNE 201 5 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: 0 O lQ Name on Certificate: Date Name of programcopyof course completion certificate) Applicant Name (mYYYY) (attach ekklSe Bcs ttrtz, �a - �� 1 - 00 5i9 1 0 ge4-ciani. ekk,%e- 0 - aol(P LJ4 — coo S S \ *For list of NLCC Certified Training Programs see www.lcc.ne.gov/traininginfo.html Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: �JQ�Yv1�1 ,l avtulci.,p yr 07 — �013 "11ti1- r=�t�ttn 11 j 4 Srl a l A+ J . iof Owe` 1; e 5. Have you enclosed Form 147 regarding fingerprints? AYES FIN° Form 103 REV JUNE 2015 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 §53-131 A 1)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. /i Signature of141anager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska t County of I)V u The foregoing instrument was acknowledged before me this / date name of person acknowledged Affix Seal 40:01AL NOTARY-State of Notary Public signature Nebraska camm.Ergs.Member 4,2019 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 l03 REV JUNE 2015 Page 6 of 6 cr-- N --- ~,- . 4,6.4.2..." 3...,9_, _..... .....- _9 ....9 3..a..)9—,..... ....):,..9.. 4b— ril ,. • 4111Ir 6-.) co •,41,' •'.1 1 ;114 C tr.C6) k.. 1% ti,11 Niii 1.4 c° C e i te ..ii kc.3) t u •,„,„i, •c = 0 0 , .. 1:1 %it 8 ' c 4 E (t) iitt 1 0 taie 'a T"' ...r, (1, ...4. 11111.4 11.411r,_, 111141 Z %.... CtS (1) CO CO '1 I '*'*% 6 CZ 0 t t:le LO 0 a) 9 Z; ca c;1 ct 0 to al to L.. ti; 1 ..3 . .Li . 4t c4 0 iri Ca 0 CA 1 ( -1 ,,...7 c*. S 20._ 45 tkel ,s1 S t w c k. q tylili Ca) ' 0 Lti a.. itA ) LZ4 In 1411 o) 0 .''dc\ le))) lkilk (V) . , ''‘ 4/ 0) 6°- 6°- -6LIWALW64ifig-.0* .alr ‘ r '6 0 0 , i— .c cr) .c co 1-- fir io_ w ... Cs .._ ....., -,, ...... _.;• -:..9-%9A °-C. .55„,rg f0-65.SS-5., ...Car---a.,(79.0L0.55.055-0(gOrgrir-r-- ' q 0 I ) 0 0 ,7, k...), ig tia..4 iri VI S-3 e tu 2 I I ji 0 44) Z Z i ) •c a) ;-.) -6 0 <—c—, k6 i ) 11144 .c 1,.. CD 0 = 1 ) CJ Tts COI WO < OS 0 0 St %.," 0 , "6 43 c E 8 4,, , ) i 0C •• k.iSL pz, Qs 1 NI 0 'To.. Zi i ) 4.. .... r°14.4 x w tie) tv E --c5 a-.) 0 z.--3 (4...* 0 0 ‘s. 104 ... 0, \ CP CD 3N7Cr6r6,(6,---6:. 0 7 - 1— .= in Li x H_ X r 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 Class:._ License It: Website: www,lcc.nebraska.gov Applicant Name: /"2,W (Corporation,LLC,Partnership Ur Trade Name: 7✓ -. lam, a 111M- CD v Mle@LS V\I0 S-V) (Doing Business As) (4° ) c , n v vNA.v�C • LO AA Phone Number Con ct 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 "H.- 1. Name: 46 e- WrA G.Vr G C'1 (Please print legibly) „ _ _ , Date of Birth: . ,- , _ Last 4 SSN: How was payment made to NSF? pNSP PAYPORT Or OCHECK SENT TO NSF Ck# 2. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSF'? ONSP PAYPORT Or OCHECK SENT TOASP Ck# 3. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSP? ❑NSP PAYPORT Or OCHECK SENT TO NSP Ck# 4. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSF? DNSP PAYPORT Or OCHECK SENT TO NSP Ck# 5. Name: (Please print legibly) Date of Birth: Last 4 SSN: How was payment made to NSF? DNSP PAYPORT Or [WRECK SENT TO NSP Ck# 6. Name: (Please print legibly) Date of Birth: Last 4 SSN: ` How was payment made to NSF? DNSP PAYPORT Or OCHLCK 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. �_, rl I ..� `1 �--i c)..x f`vE 1 (� Title: , --' Y-'t 7 Name(Print): �(' i p 1� L'{lei Si tune: L--tCvl,' / L ✓t.fDate:lJ,� (31 v FORM 147 REV MAR 2015 PAGE 2 oMAHA, N Citzj ofOmaha, Wjbrasfa A,. �;14' V9 Niltbr 1819 Farnam — Suite LC 1 � r� Omaha, Nebraska 68183-0112 nw:�' ��'^ Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 ��4�. ED FEBR March 22, 2016 DRC Williams, Inc. Application to appoint Bethany E. Baratta Dba"Fountains West" manager of your present Class "I" Liquor 4714 North 120th Street License location Omaha, NE 68164 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 April 5, 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, 4614-44411.06 : Buster Brown City Clerk BJB:clj orAAHiiiA NCityofOmaha, 9\[ebrasaitAilli*"7-11641h"\--1 `�0. 4., vs? 1 1819 Farnam — Suite LC 1 . ti 'ir'i Omaha, Nebraska 68183-0112 ��. ��r�;� io '^ Buster Brown (402) 444-5550 0.o , _ - ry, City Clerk FAX (402) 444-5263 �44 = ,q. TFD FEBR1` March 22, 2016 Bethany E. Baratta Application to be appointed manager of the 808 Valentine Lane present Class "I" Liquor License location for Valley,NE 68046 DRC Williams, Inc., dba "Fountains West", 4714 North 120th Street, Omaha,NE 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 April 5, 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, , � 40e$7A0,,,,,i') 0. Buster Brown City Clerk BJB:clj No. 7,Z,' DRC Williams, Inc., dba "Fountain West", 4714 North 120th Street requests permission to appoint Bethany E. Baratta manager of their present Class "I" Liquor License location. 04-05-16;cj 02 RECEIVED Presented to Coun 1: April 5, 2016 - Approved lam' Buster Brown City Clerk