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RES 2015-1190 - Appoint Jerry J Goerig manager of Alley V STATE OF NEBRASKA .1 Pete Ricketts na JUL NEBRASKA LIQUOR CONTROL COMMISSION I 0 Governor Hobert B. Rupe 444 t.4,440, ciTy Executire Director 301 Centennial Mall 5th Floor 9 A4 A PO 13nx 95046 • NE BRA SicA Lincoln, Nebraskrt 68509-.5046 Phone(4:02r 471,2571 Fax(402)471-2814 or 402)471 237,1 "IRS USER S:00 S33 7352 iTTY) wet)address. hnrrricw,vw!cc rw Roy/ July 27, 2015 OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Jerry J, Goerig LICENSE #CK-101624 Dear Clerk: Enclosed is a copy of a manager application for Jerry J. Goerig, in connection with Alley V, 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, Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION 402-471-2571 encl. Janice M.Wiebusch Robert Batt Bruce Bailey Commissioner Chuirmun Comrmr,,,:nr,e, An Equal Opper'to:itv Errzoover I MANAGER APPLICATION office Ilse INSERT- FORM 3c •i --' ' - - NEBRASKA LIQUOR CON TROL COMMISSION 301 CENTENNIAL ivIALL SOUTI PO BOX 95046 LINCOLN.NI 68509-5046 L PI IONE:(402)471-2571 FAX.(402)471-2814 \Vebsite: \A v,,,N. teeme oy., MUST BE: V Citizen of the United States. Include copy of US birth certificate,naturalization paper or current US passport V 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. V 21 years of age or older Corporation/LLC information Name of Corporation/LLC. ' 1 Premise information .,.. , i 1 7 (::1 tel liquor License Number: 1(._.,.,/ 2 Class Type ,(..,,,..., 1\ (it ne,s an IlsdllOti le I,e Premise Trade Name/DBA: A 1.,Le ...L- I' V Premise Street Address: J i I A'A (1 .-t-:- VI County: VC) )1://ii-2 L A-- Zip Code: _IL,,_ Premise Phone Number: Email address: A 1-,70 11)- (r)* 0 F_R__,_,-""- -[-- ft Vb11/14--IT .11,11111•1400.11111111•11•••••••111111•MI. VININIMPOOMMIN•11111=11.0. 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. htt )://v4.NNw.lee.ne.clov/licens :e rch/licsearch.ozi ffigillIPPr- IIIIII.-- -row Ner,- -41111111 -11111 ' _... SIGNA URE RftrirIRE 5 :Y Cop 'ORATE OFFICER/ MANAGING MEMBER (F, '-d signatures are acceptable) i 0-ir 103 k II REV JAN 2015 1500016694 Page 2 of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: C,C-)6--A . First Name: Jf-1-\ 1)1, L'#) Ml: Cr — Home Address (include PO Box ifapplicable): I 3i/j) City: \-JV E County: 1)(2 1107 LA-5 Zip Code: b 0 1 74) Home Phone Number: 1 1-"\ -2-ielbdt16 ----t3Business Phone Number: 1=t Social Security Number: Drivers License Number& State: = Date Of Birth: Place Of Birth: 0 tilArr-A- I jV Email address: j--6),A1 - VO /v1 Are you married?If yes,complete spouse's information (Even if a spousal affidavit has been submitted) El YES .§4,1•410 Spouse's information Spouses Last Name: First Name: Ml: Social Security Number: Drivers License Number&State: Date Of Birth: Place Of Birth: APPLICANT& SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS APPLICANT - SPOUSE YEAR YEAR YEAR CITY & STATE YEAR CITY& STATE FROM TO FROM TO ,r-c- c. LIEV J MI -2-oot 2-016 it- W62,00 ti AIR I/3) i+ Form 103 REV JAN 21115 Page 3 ot 6 MANAGER'S LAST TWO EMPLOYERS YEAR TELEPHONE FROM TO NAME OF EMPLOYER NAME OF SUPERVISOR I NUMBER 2 °Ja - 1;cky G ' ? i tit . 7-lb 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. dYES ( I 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 -`t- R\' 704 6.7v - b6/2--0-}o tdkk t ittrr) f .6P 67 u rt 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? LYES ( O 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? a ES NO Form 103 REV JAN 2015 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 Name ofprogram(attach copyof course completion certificate) Applicant Name (mm/yyyy) p v e `t ' ° J 0P L— Li �6 1. �}LL© p z�R " *For list of NLCC Certified Training Programs see www.lcc nc.go‘:'trainingin(o.htni Experience: Date of Name&Location of Business: Applicant Name,�Job Title Employment: 5. Have you°enclosed Form 147 regarding fingerprints? ES NO Form 103 REV JAN 2015 Page 5or6 PERSONAL OATH AND CONSENT OF INVESTIGATION 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 053-131.01)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. 1-14-17-1- Sigilatuie of Manager Applicant Signature of Spouse ACKNOWLEDGLMENI State of Nebrask County of vol.) The foregoing instrument was acknowledged before me this 74-'67/ 7 c? (6e,- date by / name of person acknowledge Affix Seal GENERAL.NOTARY•State of Nebraska ry Public ature ) WARREN A YOUNG .m *Comm Exp.October 26,2016 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. Fo€m 103 Rry I;\N 2015 Page 6 of 6 OAHA Ark City of 0nuthab ras a ,°411111444fs giqq ZtAirk 1819 Farnam — Suite LC 1 fPI ! '`t Omaha, Nebraska 68183-0112 rh 0 „ � F, Buster Brown (402) 444-5550 o _= _ . �ti, City Clerk FAX (402) 444-5263 �qT ��,¢ FD FEBR September 1, 2015 The V-Omaha, LLC Application to appoint Jerry J. Goerig Dba"Alley V" manager of your present Class "C" and 3375 Oakview Drive Catering Liquor 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 September 15, 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 OMAHA, NF City ® Omaha, gVNebraska 4� ����7 �t� ,�►.atalreT.& t 1819 Farnam — Suite LC 1 iWITfr �! �-t � Omaha, Nebraska 68183-0112 0 O: t _,, '40 Buster Brown (402) 444-5550 ••6o= ti City Clerk FAX (402) 444-5263 -9T '�A4 PD FEBR September 1, 2015 Jerry J. Goerig Application to be appointed manager of the 17350 Pierce Circle present Class"C" and Catering Liquor License Omaha,NE 68130 location for The V-Omaha, LLC, dba"Alley V", 3375 Oakview Drive 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 15, 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, 4eLti A.02vd Buster Brown City Clerk BJB:clj No. //90 The V-Omaha, LLC, dba "Alley V", 3375 Oakview Drive, requests permission to appoint Jerry J. Goerig manager of their present Class "C" and Catering Liquor License location. 09-15-15;cj RECEIVED Presented to Council: September 15, 2015 - Approved 7-o Buster Brown City Clerk