RES 2015-1254 - Appoint Ibrahim M Nuwwarth manager of Horsemen's Park : EI ELVED
4
STATE OF NEBRASKA
t ifiVI!:i
ek
2015 SEP - I Al'''. ift Li.8 NEBRASKA LIQUOR CONTROL COMMISSION
Hobert B. Rope
'a \ i r 4.-: Governor
4 * 1 Executive Director
,;4cti rs 06-- 301 Centennial Mail South.5th Floor
CITY CLERK P 0 Box 95046
Lincoln,Nebraska 68509-5046
MAH!',, NEBRASKI Phone(402)471 2571
Fax(402)471 2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
web address http.//wwwkc.neqov/
September 1, 2015
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Manager Application Ibrahim Nuwwarah
LICENSE #CK-39822
Dear Clerk:
Enclosed is a copy of a manager application for Ibrahim Nuwwarah, in connection with Horsemen's
Park, located in Omaha.
Please present this application for manager to your City/Village Council or County Commissioners and
send us the results of their action.
Sincerely,
.i
Jacqueline Rodriguez
licensing Division i
NEBRASKA LIQUOR CONTROL COMMISSION
402-471-2571
end.
Janice K Wielnisch Robert Batt Bruce Bailey
Commissioner Charrmon Cornmts,sioner
An Equal Opportunity Employer
MANAGER APPLICATION Office use
INSERT- FORM 3c 44fEC
vr
NEBRASKA LIQUOR CONTROL COMMISSION err
301 CENTENNIAL MALL SOUTIi i 4
PO BOX 95046
LINCOLN.'NE 68509-5046
PHONE:(402)471-2571 rfirt .11"`
FAX:(402)471-2814a 't
W'ebsitc:www.lce.nebraska.gov Oitv
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
V Fingerprinted. See Form 147 for further information,this form MUST be included with your
application. b '5°t pgifr
✓ 21 years of age or older
m. C'e '� ' `^=4"�1;f` - . .-d,` v
Name of Corporation/LLC: Omaha Exposition & Racing Inc
039822
Liquor License Number: Class Type CK (if new application leave'blank)
Premise Trade NameDBA: Horsemen's Park
Premise Street Address: 6303 Q Street
City: Omaha County: Douglas Zip Code: 68117
Premise Phone Number: 402 -731-2900 Main Line
Email address: Pats@horsemenspark.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. Click on this link to see authorized individuals.
http:llwww.lcc.nc.govlicense searchflicsearch.cgi
SIGNATURE REQUIRED _ CORPORA E OfF I MANAGING MEMBER
(Faxed signatures are acceptable)
1500020160 Form 103
REV DUNE 2015
Page 2 of 6
•
n er iry * , I E 5 E � n * P
Last Name: desiallittlarietrj, First Name: r.Cr43 r -1I yt MI: 144
Home Address(include PO Box if applicable): tt? _ ___# }
City: Coyyi Aka County: {a, Zip Code: ft, 'f/a 7
Home Phone Number: -402- _Ea 3 4 Business Phone Number: .. c)4- '7 • `6,9
Social Security Number: Drivers License Number& State: NO
Date Of Birth: Place Of Birth: thi A t
Email address: A , .iwtarh G4:1-fa .
/44* d i 31 .� t1t§1Y� i �' a r} �,„ wu
ad YES ❑NO
�y."y�
4 �" ub'"d,� ,.
Spouses Last Name: yas.t } First Name: FA Yt
Social Security Number: _ - . Drivers License Number& State:
Date Of Birth: Place Of Birth: k U tAfAl'
k ,h � " `� '' E� �°� "`,�$ k �"te'
a t -'�.'�;'a€'.�°*� r�"��,r`�e+w"i�as o , ref�� "'„r 3F �' "
CITY& STATE YEAR YEAR CITY& STATE YEAR i YEAR
FROM TO FROM ' TO
o ,..' .-ro . r ku 5/*t <rit t tr4 g• .7.? st {t ahc ` ct F t-
- Fs st y( r r : 1 r1444 /9l° 5147 . jiwitto - l t41tc q(>c44
CONNETBRP(');!.SC%Aktiltt2Q/Ui
Form 103
REV JUNE 2015
Page 3 of 6
YEAR TELEPHONE
NAME OF EMPLOYER NAME OF SUPERVISOR
FROM TO NUMBER
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.
►i YES Q NO
If yes,please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mtn/yyyy) (City&State) Charge
e let id'radr ieko 4
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
►:• ES ONO
IF YES,list the name of the premise(s):
4,4 A./
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 ENO
fio
NEBRASk A Liut
CONTRai
Form 103
REV SINE 201S
Page 4 of 6
4. List the alcohol related training and/or experience(when and where)of the person •• • tLapplt 11.
*NLCC Training Certificate Issued: Name on Certificate:
NE:RASKA
CONTROL COMMiSSION
D
Applicant Name ( atemni/yyyy) Name of program(attach copy of course completion certificate)
*For list of NEC( Certified Training Programs see www.lce.ne, ovIrainin info,html
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
12114./0.1/‘ ,k/Utyl.ilei Vet 14 igsfa e5y1,1 hi/ At6-
„.0.eticy 00014,-
Y1;44 Zeilietf itri0144;cee- 11-6 1 1'4ri (4),1414-4 I
lit
(se/4460LIS /-)A
5. Have you enclosed Form 147 regarding fingerprints?
OYES ENO
"L A-4* /
0-4-1/4'.'12 176;1"
Form 103
REV IONE 2015
Page 5 of 6
r
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§53-131.01)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.
" \,,A-
Sig ire of Manager Appli nt Signatu e of use
ACK NOWLEDGEM ENT
State of Nebraska
County of z.. ,-- The foregoing instrument was acknowledged before me this
. /1" by i ru.A ,,,a- u , cl...--. .. ...
dale name of person acknowledged
C - ✓ 67
Affix Sea $ItERAI NOTARY-State Of Nebraska
... Notary ublic signature PATRICIA J.SHEFLAND
My CoErbn.EMp.December 2,2017
In compliance with the ADA,this application is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
I\,
ililik % 4 2'
a
NFR
R i,.,: i,# R Fonnta3
CONTROf C,")44 kfl 1.!!:1S ONREV JUNE2015
Page 6 of 6
•
SPOUSAL AFFIDAVIT OF Office Use
NON PARTICIPATION INSERT R E
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 t'i "`;
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX (402)471-2814 ti OR
Wetasite: x Ww.ice.f.gov I As ..
rd 0 'fin+ .� a v F`a v.'t M1 „,,,* t'99 vy :+r- ,z.: in --:.. ....
?bR'Q9 C h 1 . qr ai9 ®S e b is ,.. f ,ki t E .-¢9 0h.t r,e k.a$ -::: a v® : �N ".., 4 a.t fg a n tll.r a
t �F k }
.'yY x % _•k { b i.
*tr t x_tr a E a rc•& �' : � s i' -- a sv $ t " v a za�{ , cS. ,. tax t
� g s �� � a ,� _ 3i � te a €�pq i.
L ,4t,,, ,t Y ,r3 S.I� ,,, 8. 'J ;E ,,4 5 432 {> ,. g py b �` {td @ jt ; � f t s
re a wx s a 'a t ��ac a i �t € , ail• z acr& a°1f';str far ro€ e
g ,ram t=.° - ,, y:,4.
if
1111
/ N ' A
Ma 14 )11a AT R
Signature of spouse a ing or • aiver Printed name of spouse asking for waiver
(Spouse of individual listea-belov,�}
Nebraska
State of
Douglas
County of The foregoing instrument was acknowledged before me this
to f' by name 7 rssoon acknowledged
r
Affix SealSEKRAL"NOTI Y�.Stite ofNotary"1„,,Ze.,:_,(2
signatur PATRICIAJ.SHEFLANO
_" tity Comm F.xp.Decembee2,20t7
•
ativ, aotat le,
. 1'.477::':77'
eV /if
Signature of divi in o('' lication Printed name of applying individual
(Spouse of individual listed above)
State of "U.4--4._0 i--
County of `? 4 f,1 i41 The foregoing instrument was acknowledged before me this
edl r fir' by -.T.b,ett../i,— 17".—., dr—,--1---.
ate name of person acknowledged
Affix Seal h GENERAL NOTARY-State at Nebraska
No}tary {ibllc si" ature PATRICIA J.SHEFLAND
_,:,,. *Comm Exp.0eeetoie7 2,2017
1.
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1f2008
AHA,
City ofOmaFta Wibraska
o °M �N���
1819 Farnam —Suite LC 1
Omaha, Nebraska 681 83-01 1 2 (O9 v�r'reif F,,, 'w�
Buster Brown (402) 444-5550 r\,,
City Clerk FAX (402) 444-5263 o��T. ��,4
LD FEBR
September 15, 2015
Omaha Exposition& Racing, Inc. Application to appoint Ibrahim M.
Dba"Horsemen's Park" Nuwwarah manager of your present Class
6303 "Q" Street "C" and Catering Liquor License location
Omaha,NE 68117
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 September 29, 2015 . 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
City of Nebraska o MaijoMAHA N�
1819 Farnam — Suite LC 1 z /4t y%r
Omaha, Nebraska 681 83-01 1 2 n tr'a1
Buster Brown (402) 444-5550 •
`,o` _ y,
City Clerk FAX (402) 444-5263 o�q �g�
-et) FEBRO
September IA 2015
Ibrahim M. Nuwwarah Application to be appointed manager of the
6410 South 72°d Street, #301 present Class "C" and Catering Liquor License
Omaha,NE 68127 location for Omaha Exposition& Racing, Inc.,
Dba"Horsemen's Park", 6303 "Q" 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 September 29, 2015 . 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,
AD el'
Buster Brown
City Clerk
BJB:clj
s
No. /A-53"
Omaha Exposition & Racing, Inc., dba
"Horsemen's Park", 6303 "Q" Street, requests
permission to appoint Ibrahim M. Nuwwarah
manager of their present Class "C" and
Catering Liquor License location.
09-29-15;cj
/7 1/
RECEIVED
Presented to Council:
Sep ember 2 , 2015 - Approve
;5-1' Z1;757
•
Buster Brown
City Clerk