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RES 2015-0943 - Appoint BD Thayer manager of Millard Roadhouse 1 � �� I �� ...el � I STATE OF NEBRASKA d4 ar " r Pete Ricketts q(I 1 5 JUL - 1 All l q 9. Q NEBRASKA LIQUOR CONTROL COMMISSION � Governor LU JljL I U Hobert B. Rupe a - Executive Director 301 Centennial Mall South.5th Floor C;' Y C R K P.O. Box 95046 Lincoln.Nebraska 68509 5046 o f A I i NEBRASKA Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 TRS USER 800 S33-7352(l I Y web address.http://www.lce.ne.gov/ July 1, 2015 OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Bruce D. Thayer LICENSE #I-38249 Dear Clerk: Enclosed is a copy of a manager application for Bruce D. Thaye.r, in connection with the Millard Roadhouse, 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 Chairman Commissioner An Lqua!Oppo,tu ni l y,Employ, , MANAGER APPLICATION Mice Use Si INSERT - FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION i‘L- 301 CENTENNIAL MALL SQUI I r-- PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX: (402)471-28 i 4 Website: ne M UST BE: v Citizen d the United States I ndude copy d US birth certificate, naturalization paper or current US pasEport v Nebraska rmident. I ndude copy d voter regidraticri in the State d Nebraska Fingerprinted. See Form 147 for further information,thisform MUST be included with your application. ,7 21 yearsof age or older CorporationlLLC information Name of Corporation/LLC: Milla4 12.oaclkotp>e c. Premise information Liquor License Number: 03 Q7 2-Li Class Type I (if new application leave blank' Premise Trade Name/DBA: utt)to.vd goad Premise Street Street Address: 1332S- )AAL(Cok-I) Ave City: 0 uteia (itok County: 170 ( 5 Zip Code: 6g 13.7 Premise Phone Number: 0402-) gq scrz-q ?— Email address: BV't)c.e- ti(a 4)VZ2 • 0 h co x -t‘"( -co vIA The individual whose name is listed as a corporate dficer or managing member as reported on 'need form 3a or 3b or lived with the Commision. Click on this link to see authorized individuals http://www.lcanecwillaym r ( SI GNA URE REQUI RED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) 11 11 I I 1 '1111i II III I 1 i Form 1500015692 REV JAN 20If, Page 2 of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: -1-140, { First Name: By-Lice MI: 17 Home Address (include PO Box if applicable): t Vt- Ma(A C7+- County: Sckr .7 Zip Code: Home Phone Number: 40 Z 2-c3 2-.00 Business Phone Number: ItOZ - 3 I -9 Z-6/Z_ Social Security Number: , Drivers License Number& State: Date Of Birth: _ Place Of Birth: 5.ife,t/lotr . Email address: 't;A,f-vc.,4„-RAANte/4/7 w- il Are you married?If yes,complete spouse's information(Even if a spousal affidavit has been submitted) EYES F NO Spouse's information Spouses Last Name: TALL tirA7- First Name: MI:Social Security Security Number: Drivers License Number& tate: ,E Date Of Birth: Place Of Birth: 041.,..a k.c4 - APPLICANT& SPOUSE MUST LIST RES DENCE(P FOR THE PAST TEN(10)YEARS APPLICANT SPOUSE YEAR YEAR CITY & STATE YEAR CITY & STATE YEAR FROM TO FROM TO _ COp141416.e1d M6 -zo05- 2VIç 55eA, k)E- 7-?0S ( 1-orm REV JAN 2OIi Page 3 of 6 , MANAGER'S LAST TWO EMPLOYERS j YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER lq' q 7-0!L+ Ov-a(NO € .S 1144-7 VtCAIC r6t Ito r-e. 402 - ((v4-1706 2ov-f z7(5 c► Fire-AA rZe_covei Navk 4i&ti f- —S"55y - ►7-2-I 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by bcth applicant and spouse; unless spouse has filets an affidavit cf non- partidpation. 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 n 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 _ Bryce Q Tom. ems/ hJeISan uE c ur — ?JW Le. P Zl�.ct1e 7 I�%S (. 1Ac0(w, ).S( �7 U iv�.l 6 -1 l c.e 6/2,015 G IJI t-s Seize-dal' (A,t i (+l 2. Have you or your spouse ever been approved or made application for aiiquor license in Nebraska or any other state? nYES NO 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? V YES LINO FOIID IOJ RrV JAN 20I'1 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 Name of program(attach copy of course completion certificate) (mm/YYYY) *For list of NLCC Certified Training Programs see www.lec,ne 12ov trainimlinfo.htin: Experience: Date of Applicant Name/Job Title Name&Location of Business: Employment: to...02., 1 q612-- Prbr (IA IA 5,17vi-t-..v •etoct, 6tocci 11-c<le,v- tclq De-vv-Per to. 5 i/Itri N_Ye- 6S"-orf ii '1/4,ri SOL 5. Have you enclosed Form 147 regarding fingerprints? ES ONO Form 103 REV JAN 2015 Page 5 of 6 ` PERSONAL OATH AND CONSENT-OF INVESTIGATION: The above inJividkua|(s) being first duly swnM upon outh, deposes and states that the undersigned is the applicant and/or yPOuSeo[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. lf any false statement iu made in any pad of this application, the applicant(s) yhu|| be deemed guilty of perjury and nu6iccL to penalties provided bylaw. (See 053-l3l.0i)Nebraska Liquor Control Act. The undersigned applicant hereby consents to on investigation u[his/her background including all records of every kind and description including police records, tax records (State and Federal), and bank or lending institution rcuwodu, and said applicant and spouse waive any rights urcauses of action that said applicant or spouse may have against the Nebraska Liquor Control Curnmninuioo and any other individual disclosing or releasing said information to the Nebraska Liquor Control Commission. If spouse has NO interest directly o, indirectly, u spousal affidavit u[non participation may heattached. The undcruiflned understand and acknowledge that any \iocnac issued, based un the information submitted in this application, is subject to uuoco|\abun if the information contained herein is incomplete, inuccurute, or fraudulent. ' Signature of - K4="ra"°'&pp|icant S � of ~^ac AC KNOW FwI-,N T State ofNeb County of (/ The foregoingin�umentw�uoknow|��d��mc�io -----�-7 { Gun P— -10 '_7/}/ �� by 4 /l date ��» O xmxxca/ Notary Public signature GENERAL NOTARY'State ofNebraska MORG«mC.KVDLACEm Mv COMM.s,p�SePt.20.2015 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. Fom /m REV mwzu/s ��Y��|�� m�6 a 6 SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOT1i11 PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 := t ,, FAX (402)471 2814 Webstte r, b ,,t s i_i - t,l I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any interest,directly or indirectly in the operation or profit of the business(§53-125(13))of the Liquor Control Act. I will not tend bar,make sales,serve patrons,stock shelves,write checks,sign invoices or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be required;however, I am obligated to sign and disclose any information on all applications needed to process this application. i , , (1 i x i , �. tit t Signature of spetise asking for,�`vaiver Printed name of spcluse asking for v iver (Spouse of individual listed below) State of \- to r a 6.CA-"" County of „)(9-4' '7)t The foregoing instrument was acknowledged before me this L CirV CI t.0 i S by i4YY tl_,^ -1-hC1..i,/1 date name of person acknowledged L " Affix Seal °t C{ � GENERAL NOTARY State of Nebraska tary Public signature 1 MORGAN C.KUDLACEK e?' 1. 11 My Comm.Exp.Sept.20,2015 li I acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-I25(13))the Commission may cancel or revoke the liquor license. /; ; i _ tt Signature of individual nvolved with application Printed name of applying individual (Spouse ofindividual listed above) State of It/ io1 L c County of '' The foregoing instrument was acknowledged before me this r (2-4/)--- a9 _S` by r (•? C9IOI te name of person acknowlted L' ` '( 1'i ' ! 1 Ce.�;f~t, Affix Seal e4 GENERAL NOTARY•State of Nebraska No 1yL-``�"Public signature it MORGAN C.KUDLACEK e_r My Comm.Exp.Sept.20,2015 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 cn writing to produce the alternate format. FORM 35-4178 Revised 1/2008 City of Nebraska oMAxA, �,�� '� 'r��1819 Farnam — Suite LC 1 zWO. j� �' `'i "I Omaha, Nebraska 681 83-01 1 2 w. :r-4-‘7Agm) Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 RTED FEBRUe' July 14, 2015 Millard Roadhouse, Inc. Application to appoint Bruce D. Thayer 13325 Millard Avenue manager of your present Class "I" Liquor Omaha, NE 68137 License location 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 July 28, 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. Sincer yyours,ee Buster Brown City Clerk BJB:clj ('ity of Omaha Nebraska OMAHA, N 1819 Farnam - Suite LC 1 r',r 'c r� Omaha, Nebraska 681 83-01 1 2 n , v,: �'^ Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 -s 4� 4ED FEBRUA July 14, 2015 Bruce D. Thayer Application to be appointed manager of the 12514 Main Street present Class "I" Liquor License location for Springfield,NE 68059 Millard Roadhouse, Inc., 13325 Millard Avenue 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 July 28, 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 No. W-3 Millard Roadhouse, Inc., 13325 Millard Avenue, requests permission to appoint Bruce D. Thayer manager of their present Class "I" Liquor License location. 07-28-15;cj Liq RECEIVED Presented to Council: July 28, 2015 - Approved - o Buster Brown City Clerk