RES 2015-0889 - Appoint Pamela L Perry manager of Harry A Koch Trap & Skeet Range L - UON
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Pete Ricketts *"'° u=" °° ^ '' — - NEBRASKA LIQUOR CONTROL COMMISSION
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June �(l 2OI5
OK4AHA CITY CLERK
1819 FARNAk4 STREET LC-1
[)K4AHA NE 68183
RE: Manager Application Pamela L. Perry
LICENSE #1-107564
Dear Clerk:
Enclosed is a copy of manager application for Pamela L. Perry, in connection with the Harry A. Koch
Trap {k Skeet Range' located in C)nneha.
Please present this application for manager to yOurCity/Village Council Or County Commissioners and
send us the results of their action.
Sincerely,
l
Jacqueline Rodriguez /
Licensing Division
NEBRASKA LIQUOR CONTROL COMMISSION
402-47I-2571
encl.
Janice M. mse6vsc» Robert Batt Bruce Bailey
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
FAX:(402)471-2814
Website: wro,‘ lec.ne ao‘
MUST BE:
• 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
✓ Fingerprinted. See Form 147 for further information, this form MUST be included with your
application.
• 21 years of age or older
Corporation/LLC information
City of Omaha
Name of Corporation/LLC:
Premise information
107564
Liquor License Number: Class Type (irne,A applftation caveI blank)
Premise Trade Name/DBA: Harry A Koch Trap & Skeet Range
Premise Street Address:6802 Harrison Street
City:Omaha
County: Douglas
Zip Code:68128
Premise Phone Number:402-331-1249
Email address: N/A
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.govilicense search/licsearch.cgi
•/ : -
SIGNATURE REQUIRED BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
1111 11 11111 111REV
Form 103
JAN 2015
Page 2 of 6
1500015694
Manager's information must be completed below PLEASE PRINT CLEAIIL) .,ki 9 a. lair
Last Name: Pe,'121 First Name: A_ vIc,{ 1 ME; L-
,p
Home Address(include PO Box if applicable): 1301,1City: otyt a ti County: bc Zip Code: (,431.6•71-1
Home Phone Number: -102. 1-41-16-9 ci Business Phone Number: L102_ 2-1-46(
Social Security Number: Drivers License Number& State:
Date Of Birth: Place Of Birth: Oil &
Email address: 7 4tvQ-14t— 7.4 ra."-y 62)(44-11 (')/vici-ka • 6'15
Are you married? If yes,complete spouse's information(Even if .a'spousal affidavit has been submitted)
PA YES NO
Spouse's information
Spouses Last Name: First Name: r) Ml: g
Social Security Number: rivers License Number& State:
Date Of Birth: Place Of Birth: /Dc--_,5
APPLICANT&SPOVSK MUSTLIST ftE THE PAST TEN(10) YEARS
APPLICANT S USE
YEAR YEAR
CITY & STATE YEAR CITY & STATE YEAR
FROM TO FROM TO
icih
//,'//;"-- i 9 7 ,2.e)i
Joni, 103
R1 V JAN 2015
Page 3 of 6
MANAGER'S trnr-TWO:.tMPLOYEE:S,
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR
TELEPHONE
FROM TO NUMBER
A r
)801 1°544' U4 c Ot441.1(X, ,tw-ya- , 7
Platiz.,,,obitheith Lit 1,--I-1 -5104)
11.4 1.4 f500
. 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 an\ 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 17 NO
If yes, please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Di sposin on
(mm/yyyy) ( 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?
YES ONO
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?
FXYES F-NO
Ftala 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:
Applicant Name ( Name of program (attach copy of course completion certificate)
mm/yyyy)Date
D 1 L.-7)
i txAs,p..2., CL/ / ,..)----k-) D.. 7-32_o i 6
L 1,---1 -dfr.,;Z.0 i,5 1 .c.e.3i9c."(N5 g-L4) BiQ.,,,i •a et-5,e., . Ei2.-Vit c rf 4 f xi'‘' "
L. 0--1
......
4- 1 7-26 t5
*For list of NLCC Certified Training Programs see wvvwlec.ne.govitraininginfo.html
Experience:
Date of
Applicant Name/Job Title Name& Location of Business:
Employment:
?fkANNO I INA-1(2-‘21 )RI.t SAC(C.41c(h i Ci 171-
<.,.
5. Have you enclosed Form 147 regarding fingerprints?
NES NINO
I orm 103
RI V IAN 2.015
Page 5 ot 6
PERSONAL OATH AND CONSENT OF INVESTIGA 'ION
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.
J It e":
Signature of Ma alter Ap 1 ant Signature-opouse
ACKNOWLEDGEMI Ni"
State of Nebraska
County of �J ' lt' The foregoing instrument was acknowledged before me this
by f►'►1 /c.. e p r p 1 )e4 (�
' 1 r t1
date name f person acknowledged
Affix Sep ,
Notary Public signature• '`��t�Pc STEVEN R.SLATER
`.7:7`: MY COMMISSION EXPIRES
September 7,2016
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.
Font 103
REV JAN 2015
Page 6 of 6
SPOUSAL AFFIDAVIT OF Office Use
NON PARTICIPATION INSERT
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE'(402)471-2571
FAX.(402)47I-2814
Website' w_V,A lee ne gn...
I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will ih thave 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.
�'..._->�---=-- : ' . 47--. Da v,'f R. 1 r")
Signature of spouse asking for wa `e' Printed name of spouse asking for waiver
(Spouse of individual listed below)
State of '4,,'c e' (45
County of ,'‘ 4,c The foregoing instrument was acknowledged before me this
C'/. �/S by 111,,y,i / f-r `"f
date name of person acknowledged
Affix Seal
: .'s�"�s -, STEVEN R.SLATER
"
Notary Public signature ~ =j "•`="`f" MYCOAMIISSIONEXPIRES
1...nrr
s: ngii:`` September 7,2016
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(§53-125(13))the
Commission may cancel or revoke the liquor license.
--e I_ , R4v-v‘e. L A L. 9- tom-v.
Signature of individual involved ith application Printed name of applying individua(�
(Spouse of individual listed above)
1V62State of '1 'j ✓,
County of PoU . ;)✓'4 The foregoing instrument was acknowledged before me this
/l by wog /cam 4- 'er,rl
date name of person acknowledged
Affix
�._
�, .. Seal
:ir,,�..\ STEVEN R.SLATER
Notary Public signature =.:°E-Z:),I
�:;".}•_ MY COMMISSION EXPIRES •
3" 4-: *Amber 7,2016
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 1/2008
ioNa 278 198
SerevSafe CARONO 071443
ServSaf* AiC01101® ADVANCED CERTIFICATE
PAMELA PERRY
Card exPires,Direeyeara'Dorn thfdate of Mte exaMination.Localiaws apply.
DATE OF EXAMINATION
2/2,3/201 5
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1 NEBRASKA
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— COMMISSION
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1 Certified Aiclihol Server
,
NuPinbaer .ela Perry
1 Didaetnetiflofcaisstnee:04/17 1500024042/2015
Date of Expiration:02/23/2018
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City of®maw, 9'Lthraska 4 �,p
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WVP"tkr.ett- VS,
1819 Farnam — Suite LC 1 z V�'gf ��r
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Omaha, Nebraska 681 83-01 1 2 ntv,r41co
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Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263
TFD FE1303''
July 7, 2015
City of Omaha, A Municipal Corporation Application to appoint Pamela L. Perry
Dba"Harry A Koch Trap & Skeet Range" manager of your present Class "I" Liquor
6802 Harrison Street License location
Omaha,NE 68128
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 21, 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,
46‘40,
Buster Brown
City Clerk
BJB:clj
City o OmaFtq, 9[thrasIa FMHA/k"�8Mihte
1819 Farnam — Suite LC 1 7 Of r OM ftt
Omaha, Nebraska 68183-0112 n „.r1 k '^
Buster Brown (402) 444-5550 �o - : _ _ N.
City Clerk FAX (402) 444-5263 Y -s 4�
9-176'0
FEBRUP
July 7, 2015
Pamela L. Perry Application to be appointed manager of the
13011 Browne Circle present Class "I" Liquor License location for
Omaha, NE 68164 City of Omaha, A Municipal Corporation, dba
"Harry A Koch Trap & Skeet Range", 6802 Harrison
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 July 21, 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,
4‘AP
Buster Brown
City Clerk
BJB:clj
No. 889
City of Omaha, A Municipal Corporation, dba
"Harry A Koch Trap & Skeet Range", 6802
Harrison Street, requests permission to appoint
Pamela L. Perry manager of their present Class
"I" Liquor License location.
07-21-15;cj
/g
RECEIVED
Presented to Council:
July 21, 2015 -Approved 7--
Buster Brown
City Clerk