RES 2018-1061 - Class I liq lic to Grown Folks City Clerk Office Use Only:
•
/r � Publication Date November 12, 2018
■U RESOLUTION NO.
Agenda Date: November 20,2018
Department: City Clerk
Submitter: Carman Johnson
•
CITY OF OMAHA
LEGISLATIVE CHAMBER •
• Omaha, Nebraska
RESOLVED BY THE CITY COUNCIL OF THE CITY OF OMAHA:
THAT, in accordance with the provisions of the Nebraska Liquor Control Act, as
amended, after a hearing held within 45 days after receiving notice and a copy of the license
application and upon due consideration of all standards and criteria provided by law,this
Council hereby recommends that the following application for a Class "I" Liquor License
be granted.
1093R Investments, LLC, dba"Grown Folks", 3713 North 24th Street.
That, the cost of publication of notice of the hearing was $26.00.
•
•
•
Adopted: Nov mbe `20 2018 6-1 Na : Jerram
t 1 , alltaillu„
Attest:
DEPUTY City Clerk 1'
Approved: I -Z�U Li
Mayor
RES Nat
G
TYPE OF LICENSE: CLASS "I" LIQUOR LICENSE
NAME & ADDRESS: 1093R INVESTMENTS, LLC
DBA "GROWN FOLKS"
3713 NORTH 24TH STREET
RECEIVED: OCTOBER 22, 2018
45TH DAY: THURSDAY, DECEMBER 6, 2018
HEARING DATE: NOVEMBER 20, 2018 - 29TH DAY
AND/OR PERSONS CONTACTED: GEORGE ROBINSON
402-290-7249
ATTORNEY-GRANT FORSBERG
C/ 402-216-0216
POSTED: 11-
NOTIFIED: /1 q �/ r
NEW APPLICATION, NEW LOCATION.
RECEIPT 10- 19-2018
NEBRASKA LIQUOR CONTROL COMMISSION
e
From: TRACY BURMEISTER OCT 22'18 PH2:443
City Clerk Omaha HE-RCVD
Email: TRACY.BURMEISTER@nebraska.gov
Phone: (402) 471 - 2572
Fax: (402) 471 - 2814
Emaill: City Clerk of Omaha- carman.johnson@cityofomaha.org
Applicant: 1093R Investments LLC dba Grown Folks
License #: Class 1-122838
Please sign and date stamp this receipt and return back to the NLCC office
•
Date of ReceiptQc
pplication
af-4-4---21.A CT)130-e-1-•-
Signature
TWO KEY DOCUMENTS
1) The receipt page will need to be signed, dated and returned back into the NLCC office either via
APPLICATION FOR LIQUOR LICENSE
CHECKLIST-RETAIL
NEBRASKA LIQUOR CONTROL COMMISSION 1 L. { 5 ZU I8
301 CENTENNIAL MALL SOUTH,
PO BOX 95046
LINCOLN,NE 68509-5046 NEBRASKA LIQUOR
PHONE:(402)471-2571
FAX:(402)471-2814 CONT. •L COMMISSION
Wcbsitc:www.lcc.nebraska.gov
g? �= eplacing#
_
122838 iEy
Applicant name b O 9 3 R /n/ e S lM f✓1 i-,S I IL
Trade name G LCAAJA\\n Fe) ) K S
Previous trade name N I IS
Contact email address . C(ObNN 300(a Mkt cc —'
Provide all the items requested. Failure to provide any item will cause this application to be returned or placed on
hold. All documents must be legible. Any false statement or omission may result in the denial, suspension,
cancellation or revocation of your license. If your operation depends on receiving a liquor license, the Nebraska
Liquor Control Commission cautions you that if you purchase, remodel, start construction, spend or commit money
that you do so at your own risk. Prior to submitting your application review the application carefully to ensure that
all sections are complete, and that any omissions or errors have not been made. You may want to check with the
city/village or county clerk, where you are making application, to see if any additional requirements must be met
before submitting application to the Nebraska Liquor Control Commission.
•
•
——
-
GK
e bp.1
AMOUNT: 400 III 111111 II III IIII II
• Received: - 1800012905
FORM 100
awii \ REV FPAGE 1
1. •
✓ Fingerprints are required for each person as defined in new application guide, found on our website under
"Licensing Tab"in"Guidelines/Brochures". See Form 147 for further information,this form MUST be included with
your application. •
2. Enclose application fee of $400 (nonrefundable), check made payable to the Nebraska Liquor Control
Co ssion or you may pay online at PAYPORT.
3: t Enclose the appropriate application forms;
Individual License(requires insert form 1)
Partnership License(requires insert form 2)
Corporate License(requires insert form 3a&3c)
• • Limited Liability Company(LLC)(requires form 3b&3c)
4. ' 4ViirIf building is being leased send a copy of signed lease. Be sure the lease reads in the name of the individual(s),
corporation or Limited Liability Company(LLC) making application. Lease term must run through the license year
being applied for.
•
5. /If building is owned or being purchased send a copy of the deed or purchase agreement in the name of the
applicant.
6. NIA- If buying the business of a current liquor license holder:
a. Provide a copy of the purchase agreement from the seller(must read applicants name)
b. Provide a copy of alcohol inventory being purchased(must include brand names and container size)
c. Enclose a list of the assets being purchased(furniture,fixtures and equipment)
7. wit If requesting to operate on current liquor license; enclose Temporary Operating Permit(TOP)(Form 125).
8. N illL)ynclose a list of any inventory or property owned by other parties that are on the premises.
9. �/ For citizenship enclose U.S. birth certificate-Th
S.passport or naturalization paper
a. For residency enclose proo o registered voter in Nebraska
b. If permanent resident include Employment Authorization Card or Permanent Resident Card
e. See guideline for further assistance
10. Y Corporation or Limited Liability Company(LLC)must enclose a copy of articles of incorporation; as filed with
the Secretary of State's Office.
11. " Submit a copy of your business p plan.
•
I acknowledge that this application is not a guarantee that a liquor license will be issued to me, and that the average
processing period is 60 days. Furthermore, I understand that all the information,is truthful and I accept all
responsib'ity for any false documents.
Signature
w--ir-tb1
Date .
• FORM 100
REV FEB 2017
PAGE 2
APPLICATION FOR LIQUOR LICENSE RECEIVED
RETAIL
NEBRASKA LIQUOR CONTROL COMMISSION OL' 1 ) -
oie
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE68509-5046 NEBRASKA LIQUOR
PHONE: -2814 CONTROL COMMISSION
FAX:(402)471-2814
Website:www.Icc.ncbraska.gov/
1 4$a OFPgENSE FOR WIITCH AP IS LIGATION MADE AIVDFEE$1"„ , , :.
ICI3ECICDESIRED CLASS • ",-.:.`Srsez
RETAIL LICENSE(S) Application Fee$400(nonrefundable)
A BEER,ON SALE ONLY
B BEER,OFF SALE ONLY
C BEER,WINE, DISTILLED SPIRTS,ON AND OFF SALE
D BEER, WINE,DISTILLED SPIRITS,OFF SALE ONLY
�( I BEER,WINE,DISTILLED SPIRITS,ON SALE ONLY
.1 LIMITED ALCOHOLIC LIQUOR,OFF SALE—MUST INCLUDE SUPPLEMENTAL FORM 120
AB BEER,ON AND OFF SALE
AD BEER ON SALE ONLY, BEER,WINE, DISTILLED SPIRITS OFF SALE
IB BEER, WINE,DISTILLED SPIRITS ON SALE,BEER OFF SALE ONLY
Class K Catering license(requires catering application form 106) S 100.00
Additional fees will be assessed at city/village or county level when license is issued
Class C license term runs from November 1 —October 31
All other licenses run from May 1 —April 30
Catering license(K)expires same as underlying retail license
;CHECK TYPE OF LICENSE FORWAICII.YOU ARE-APPLYING
Individual License(requires insert 1 FORM 104)
Partnership License(requires insert 2 FORM 105)
Corporate License(requires insert 3a FORM 101 &3c FORM 103)
Limited Liability Company(LLC)(requires form 3b FORM 102 &3c FORM 103)
AME OF ATTORNEY OR FIRM ASSISTING WITH APPLICATION4(1f;.appLable) r y"
LComm2ssto wI1! call;fliispersomwith anyguesdons wemay have on thts_appLcahon
Name eIM* t S 3 Phone number: 1 (7a\' at(,--eat
Firm Name ?5Is\39.1-t) "f 1`A:,
tie 35
0/440 LA , le ell
FORM 100
REV FEB 2017
PAGE 3
WREMISKSWOY2MATION n�. C.:.. 1/ NPe' : c, ': 1
Trade Name(doing business as) l7rOU3 fl D l hs
Street Address in 3913 N , ay 01 St.
Street Address#2
City QrA County t/CU()I( Zip Code Co
Premises Telephone number ,
W
Business e-mail address O{b'O � 43oo Atk ' C. —�
Is this location inside the city/village corporate limits: YES t/ NO
Mailing address(where you want to receive mail from the Commission)
Name Gigo -EL L. rP\�Di/oiN
- `t
Street Address#1 ((e -1DP1 CA'
Street Address#2 n `
City °M"I A- State 'V (a Zip Code a 155 o�
ESCRH'TION AND DIAGRAM OF THE STRUCTURE TO 3E ErCENSED .77 17. a y3 ((
BREAD C1 t EFUL Y; z A
In the space provided or on an attachment draw the area to be licensed. This should include storage areas,basement,outdoor
area, sales areas and areas where consumption or sales of alcohol will take place. If only a portion of the building is to be
covered by the license,you must still include dimensions(length x width)of the licensed area as well as the dimensions of the
entire building. No blue prints please. Be sure to indicate the'direction north and number of floors of the building.
•*For on premises consumption liquor licenses minimum standards must be met by providing at least two restrooms
Building:length * x width 240 in feet r:
Is there a basement? Yes t/ No If yes,length ' I I(o x width �.-\o in feet
Is there an outdoor area? Yes No—V - If yes,length x width in feet
PROVIDE DIAGRAM OF AREA TO BE LICENSED BELOW OR ATTACH SEPARATE SHEET
a (e
Y6
Lilo (/ t
•
FORM 100
REV FEB 2017
PAGE 4
9/12/2018 Douglas County Account Information
_ - MIXED RETAIL STORE/RESIDENTIAL
Vr 3713 N 24TH STREET
2UNITS
FJSI Floor F spp
119fi 0s1 '6 1196051s1
y Y 1499
'{Y
T>��zi I II
CLICK TO ENLARGE IMAGE ._.r....
CLICK TO ENLARGE IMAGE
Square Footage: 2392.0 Percent Complete: 100.0%
Perimeter 144.0 Quality: Average
Unit Type: Condition: Fair
Built As: Mixed Retail w/Res Units Condo Square Footage: 0.0
HVAC: Forced Air Rooms: 0.0
Exterior: Units: 2.0
Interior: Baths: 0.0
Roof Cover: Bedrooms: 0.0
Roof Type: Flat Stories: 2.0
Floorcover: Foundation:
Sprinkler Square Footage: 0.0
Year Built Year Percent Adjusted Year Physical Age
Remodeled Remodeled Built
1920 0 0% 1920 0
Detail Type Detail Description Units
Basement Storage 1196.0
http:l/douglascone.wgxtreme.com/java/wgx_douglasne/statidaccountinfo.jsp?accounino=R2015130000 2/3
CITY OF OMAHA •• ' THE DAILY RECORD
PUBLIC HEARING NOTICE OF OM A H A
NOTICE IS HEREBY GIVEN that the City l�ll'��'1
Council of the City of'Omaha, Nebraska,will LYNDA H. I3ENNINGSEN, Publisher
hold public hearings on November 20,
2018, at 2:00 PM In Legislative Chambers, PROOF OF PUBLICATION
1819 Famam Street,Omaha,Nebraska 68183.,
The purpose of these hearings is to consider
approsvalof: UNITED STATES OF AMERICA, 1
l Jll
The State of Nebraska,
Class "Cr Liquor License for.Arctic District
District of Nebraska,
•
Restaurant, L.LC., dba "Mayne St Market", County of Douglas,
located at 6207 Maple Street
City of Omaha,
Class"C Liquor License for Barks N Brews,
LLC,dba"Barks N Brews",located at 13730"P" J.BOYD
•
Street.
Class 'C Liquor license for The Jewell, being duly sworn,deposes and says that she is
LLC,dba The Jewell",located at 1030 Capitol LEGAL EDITOR
Avenue.
Class"E'liquor License for The Jewell, LLC, of THE DAILY RECORD, of Omaha, a legal newspaper,printed and
dba The Jewell", located at 1030 Capitol published daily in the English language, having a bona fide paid
A`en1e circulation in Douglas County in excess of 300 copies, printed in
Class'I'liquor License Oil-Archery Games Omaha,in said County of Douglas,for more than fifty-two weeks last
Omaha, LTD, dba "Archery Games Omaha", past; that the printed notice hereto attached was published in THE
located at 11106"Q"Street.
DAILY RECORD-of •
Class "I' Liquor License for 1093R Novem er'1° 2018
Investment,LLC,dba"Grown Folks", located •
at 3713 North 24"Street
Class"1^Liquor License for RamDas, LW,
dba"Rama Thal Restaurant",located at 17903 j
Pierce Plaza.
That said Newspaper during that time was ��• • e e lished and
Class 'Cr Liquor License for Jade and general circulation in the County of Do 9 _ � e f Nebraska
Brothers,U.C,dba"Jades Dirr,vmt Tobacco&
--
Liquor, located at 721 North 120"Street. GENERAL NOTARY-Sit of Nebras ;. Asiiiii
ELLEN FREEMAN Subs in 1L ,,.and sworatobefore
Class s Liquor License for der t, LLC, r• s M Comm.Ex .;lift 11 2021
dba 'Everest Gasman; located at 5188 y �'I V•� �
Leavenworth Street Publisher's Fee $ me this IIyy of
November 2S
Anyone Interested .In these matters'.or Additional Copies $ 20_
desiring to give evidence in support of or in 40.10 ,z.-1
protest against the Issuance of such license Total $
should be In attendance at this meeting. • Notary Public in and for Douglas County,
Elizabeth Butler,CMC State of Nebraska
= City Clerk q
City of Omaha
11-12-18 r
•
(Please publish in the Daily Record on November 12, 2018)
Please charge to General Order NO. 2447 H
CITY OF OMAHA
PUBLIC HEARING NOTICE
NOTICE IS HEREBY GIVEN that the City Council of the City of Omaha, Nebraska, will hold a
public hearing on November 20, 2018, at 2:00 PM in Legislative Chambers, 1819 Farnam Street,
Omaha,Nebraska 68183. The purpose of this hearing is to consider approval of a Class "P"
Liquor License for 1093R Investments, LLC, dba"Grown Folks", located at 3713 North 24th
Street.
Anyone interested in this matter or desiring to give evidence in support of or in protest against
the issuance of such license should be in attendance at this meeting.
Elizabeth Butler, CMC
City Clerk
City of Omaha
NOVEMBER 20, 2018—RES # 1 i� 4 �j) MOTION
D BY tt� TO GRANT
l�U' •
APPROVED
V el � er'
1 unl�lp
1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY §53-125(5)
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.
Include'traffic violations. Commission must be notified of any arrests and/or convictions that may occur after the date of
signing this application.
YES NO
If yes, please explain below or attach a separate page
Name of Applicant Date of Where Description of Charge Disposition
Conviction Convicted
(mm/yyyy) (city&state)
Gknipit L. Rc1oih ) 2o((c 11w015 Sp-eect A^:3 Say-A r n�
2. Are you buying the business of a current retail liquor license?
YES 5c s NO
If yes,give name of business and liquor license number
a) Submit a copy of the sales agreement
b)Include a list of alcohol being purchased,list the name brand,container size and how many
c)Submit a list of the furniture,fixtures and equipment
3. Was this premise licensed as liquor licensed business within the last two(2)years?
YES X NO
If yes,give name and license number
4. Are you filing a temporaryoperating permit(TOP)to operate during the application process?y/
YES X. NO
If yes:
a) Attach temporary operating permit(TOP)(Form 125)
b) TOP will only be accepted at a location that currently holds a valid liquor license.
FORM 100
REV FEB 2017
PAGE 5
5. Are you borrowing any money from any source,include family or friends,to establish and/or operate the business?
YES X NO
If yes,list the lender(s)
6. Will any person or entity,other than applicant,be entitled to a share of the profits of this business?
YES X NO
If yes,explain. (al involved persons must be disclosed on application)
No silent partners
7. Will any of the furniture, fixtures and equipment to be used in this business be owned by others?
YES X NO
If yes,list such item(s)and the owner.
8. Is premises to be licensed within 150 feet of a church,school,hospital,home for the aged or indigent persons or for
veterans,their wives,and children,or within 300 feet of a college or university campus?
YES y NO
If yes,provide name and address of such institution and where it is located in relation to the premises(Neb.Rev. Stat.
53-177)(1)
Provide letter of support or opposition,see FORM 134—church or FORM 135-campus
9. Is anyone listed on this application a law enforcement officer?
YES X NO
If yes,list the person,the law enforcement agency involved and the person's exact duties.
10. List the primary bank and/or financial institution(branch if applicable)to be utilized by the business.
a) ist the individual(s)who will be authori d jo write checks and/or withdrawals on accounts at this in titution.
Fksa 1\14-flew,. ,1 f3yorhk
11. List all past and present liquor licenses held in Nebraska or any other state by any person named in this application.
Include license holder name, location of license and license number. Also list reason for termination of any license(s)
previously held.
•
FORM 100
• REV FEB 2017
PAGE 6
•
12. List the alcohol related training and/or experience(when and where)of the person(s)making application. Those persons
required are listed as followed:
• Individual: Applicant and spouse;spouse is exempt if they filed Form 116—Affidavit of Non-Participation..
• Partnership: All partners and spouses,spouses are exempt if they filed Form 116—Affidavit of Non-Participation.
• Limited Liability Company: All member of LLC,Manager and all spouses;spouses are exempt if they filed Form
116—Affidavit of Non-Participation.
• Corporation: President, Stockholders holding 25%or more of shares,Manager and all spouses; spouses are exempt if
they filed Form 116—Affidavit of Non-Participation.
NLCC certified training program completed:
Applicant Name Date Name of program(attach copy of course completion certificate) ,
(mm/my)
List of NLCC certified training programs
Experience:
Applicant Name/Job Title Date of Name&Location of Business
Employment:
13. If the property for which this license is sought is owned,submit a copy of the deed,or proof of ownership. If leased,
submit a copy of the lease covering the entire license year. Documents must show title or lease held in name of
applicant as owner or lessee in the individual(s) or corporate name for which the application is being filed.
Lease: expiration date
Deed
Purchase Agreement
14. When do you intend to open for business? \ 1acA 1
15. What will be the main nature of business? S-Al& 1 kkoi \16. What are the anticipated hours of operation? �� c�� (ocCos S�t (�
�.0.()
17. List the principal residence(s)for the past 10 years for all persons required to sign,including spouses.
aJRESID •EICS FOR TJIE PAST IO YEARS,APPLICANT AND SPOUSE) Q T COMP• ..._.4:1„,,,,,,,n44Wwc
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
FROM TO FROM TO
•
•
()AA&-P4A1 oUL G1 PreaJ \Orti.✓} fvLS (PY %<.
If necessary attach a separate sheet. •
•
• FORM 100
REV FEB 2017
PAGE 7
The undersigned applicant(s) hereby consent(s) to an investigation of his/her background and release present and future records of every kind and
description including police records,tax records(State and Federal),and bank or lending institution records,and said applicant(s)and spouse(s)waive(s)
any right or causes of action that said applicant(s)or spouse(s)may have against the Nebraska Liquor Control Commission,the Nebraska State Patrol,and
any other individual disclosing or releasing said information. Any documents or records for the proposed business or for any partner or stockholder that
are needed in furtherance of the application investigation of any other investigation shall be supplied immediately upon demand to the Nebraska Liquor
Control Commission or the Nebraska State Patrol. 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.
Individual applicants agree to supervise in person the management and operation of the business and that they will operate the business authorized by the
license for themselves and not as an agent for any other person or entity. Corporate applicants agree the approved manager will superintend in person the
• management and operation of the business. Partnership applicants agree one partner shall superintend the management and operation of the business. All
applicants agree to operate the licensed business within all applicable laws,rules,regulations,and ordinances and to cooperate fully with any authorized
agent of the Nebraska Liquor Control Commission.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity
to complete or challenge the accuracy of the information contained in FBI identification record. The procedures for obtaining a change,correction, or
updating an FBI identification record are set forth in Title 28,CFR, 16.34.
Must be signed in the presence of a notary public by applicant(s)and spouse(s). See guideline for required signatures
/ l
IJS.4(111 /.2 7?06-4,6)//1_)
Signature of Applicant Signature of Spouse
Leary e L, f a(Jt`/VcSI)Y�
Print Name Print Name
Signature of Applicant Signature of Spouse
•
Print Name Print Name
ACKNOWLEDGEMENT
State of Nebraska
Countyr of 'aS The foregoing instrument was acknowledged before me this
`X' TFP/vniOPI IL /dig by e�C�P `/36A_
date' �/ name of person(s acknow edged(individual(s)signing)
•
Notary Public ignature
:10W:NOTARY•state of Nebraska
• SHERRI L BROWN
Ay Cows. Sepl.15,2020
•
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 100
REV FEB 2017 •
• PAGER
The undersigned applicant(s) hereby consent(s) to an investigation of his/her background and release present and future records of every kind and
description including police records,tax records(State and Federal),and bank or lending institution records,and said applicant(s)and spouse(s)waive(s)
any right or causes of action that said applicant(s)or spouse(s)may have against the Nebraska Liquor Control Commission,the Nebraska State Patrol,and
any other individual disclosing or releasing said information. Any documents or records for the proposed business or for any partner or stockholder that
are needed in furtherance of the application investigation of any other investigation shall be supplied immediately upon demand to the Nebraska Liquor
Control Commission or the Nebraska State Patrol. 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.
Individual applicants agree to supervise in person the management and operation of the business and that they will operate the business authorized by the
license for themselves and not as an agent for any other person or entity. Corporate applicants agree the approved manager will superintend in person the
management and operation of the business. Partnership applicants agree one partner shall superintend the management and operation of the business. All
applicants agree to operate the licensed business within all applicable laws,rules,regulations,and ordinances and to cooperate fully with any authorized
agent of the Nebraska Liquor Control Commission.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity
to complete or challenge the accuracy of the information contained in FBI identification record. The procedures for obtaining a change,correction, or
updating an FBI identification record are set forth in Title 28, CFR, 16.34.
Must be signed in the presence of a notary public by applicant(s)and spouse(s). See guidelineid for required signatures
Cialeics(),it Ter Oie49490
Signature of Applicant Signature of Spouse
• Tin a ,f f:leak/n San--
Print Name Print Name
Signature of Applicant Signature of Spouse
Print Name Print Name
ACKNOWLEDGEMENT
State of Nebraska ,(� G1 CC
County of 1 )0 ' \.Q ) The foregoing instrument was acknowledged before me this
2,9 eh by iIWoihG EMI 1OloinSor7
date� name of person(s)acknowledged(individual(s)signing)
V •
Nota P lie signature
•
GENERAL NOTARY-State of Nebraska
TARA BENAK
• My Comm.Exp.February 3,2020
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 100
•
REV FEB 2017
PAGES
•
APPLICATION FOR LIQUOR LICENSE Office Use RECEIVED
LIMITED LIABILITY COMPANY (LLC)
INSERT-FORM3b jC T 1 ;, 2018
NEBRASKA LIQUOR CONTROL COMMISSION
30l CENTENNIAL MALL SOUTH NEBRASKA LIQUOR
PO BOX 95046
LINCOLN,NE 68509-5046 CONTROL COMMISSION
PHONE:(402)471-2571
FAX:(402)471-2814
Website: www.Icc.nebraska.gov
All members including spouse(s),are required to adhere to the following requirements:
1) All members spouse(s)must be listed
2) Managing/Contact member and all members holding over 25%interest and their spouse(s)(if applicable)must submit
fingerprints.See Form 147 for further information,this form MUST be included with your application.
3) Managing/Contact member and all members holding over 25%shares of stock and their spouse(if applicable)must sign
the signature page of the Application for License form 100(even if a spousal affidavit has been submitted)
Attach copy of Articles:bf i-ganlzahon(maast show eleCaonicstamp or barcode receipt by7Seci'etary;of States'office),
Name of Registered Agent: ( {?W� LA) R C. ) LLD, (6-104- r6ese-b-d\)
Name of Limited Liability';Company,:that will hold license as listed on'the Articles of Organization,. - : , ,*
ftR ICE
-_ne 3)
LLC Address:(�V(�i t Tj p, , f
City: re'✓A A- G State: t E Zip Code: (0 5j
LLC Phone Number: (LW ago i 4 ` LLC Fax Number
Name of Managing/Contact Member ,_ 4 4 s tin4
Nartie and>nformahon"of contact member must be listed on following page ' ) ,;`;: CcP x µ
Last Name: l bb i'Vw SON) ( r First Name: C PL z MI: L,
Home Address: 5-9{ (D —1-D 1 d T City: O try &
State: C Zip Code: W (52,— Home Phone Number: (Lrisa A I d-7D.L1
Signature of Managing/Contact Member
ACKNOWLEDGEMENT
State of Nebraska
County of I / /,, The foregoing instrument was acknowledged before me this
m ill' .AA lit - 1 . C20 I by 6e0r h . fCXtti SOA
/ na of person acknowledge
11 LCA A S Affix Seal GENERAL NOTARY-Slate of Nebraska
SHERRI L BROWN
.t a IIyCome.Etp.Sep115,2020
FORM 102
REV JUNE 2015
Page 1 of 4
tie+;,.ir rsf la i 74 ,y 7.
�.ts"t names of all members and their spouses(e" "tf a Spousal affidavit bas ttberi'subttittted) �
wt a l - _.
Last Name: (KbM SSN First Name: Geetrt_Ml: L
Social Security Number: i. Date of Birth:_ `V1
Spouse Full Name(indicate N/A if single): I t I,�S1Prini A- Mt (RO t$,r 3 - J
Spouse Social Security Number: — Date of Birtl
Percentage of member ownership ( !J V
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if single):
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if single):
Spouse Social Security.Number: Date of Birth: •
Percentage of member ownership
Last Name: First Name: MI:
•
Social Security Number: Date of Birth:
Spouse Full Name (indicate N/A if single): •
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
•
FORM 102
REV JUNE 2015
•
Page 2 of 4
a+' l lr n ..e a Tai Nr .xi*%:-r sx r cp w�• ,v.+,. F 3Pti r�P�+.dt
'List names of all members and their spouses(even if a spousal affidavit haT been subnutted)rt Z v `'
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicat:N/A if single):
Spouse Social Security Num,er: Date of Birth:
Percentage of member owners•ip ,
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if sing , :
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name(indicate N/A if single):
Spouse Social Security Number: Late of Birth:
Percentage of member ownership
Last Name: First Name: MI:
Social Security Number: Date of Birth:
Spouse Full Name (indicate N/A if single):
Spouse Social Security Number: Date of Birth:
Percentage of member ownership
FORM 102
REV JUNE 2015
Page 3 of 4
ds lie,*pplymg Limrted Liabihty.Company controlled by.another cotporahon/company? r
s
;i? :rtt.
OYES ENO
If yes,provide the following:
1) Name of corporation
2) Supply an organizational chart of the controlling corporation named above
3) Controlling corporation MUST be registered with the Nebraska Secretary of State, copy of articles must
be submitted with application §53-126
Indtcats the company's tax'.,year with:the IRS (Ekample,January througli'December) . tG `
' .r 1 h x e
Starting Date: UA-ri Ending Date: De C`e ve•
•
Is tivs a-Non Profit Corporations 4-` '
OYES NINO
If yes,provide the Federal ID#.
•
•
•
•
•
•
In compliance with the ADA,this corporation insert form 3a is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 102
REV JUNE 2015
Page 4 of 4
10/15/2018 Nebraska Secretary of State-Corporation and Business Entity Searches
Nebraska Secretary of State
1093R INVESTMENTS, LLC
Mon Oct 15 15:54:36 2018
SOS Account Number
10196447
Status •
Active
Principal Office Address
5416 IDA STREET
OMAHA, NE 68152
Registered Agent and Office Address
FORSBERG LAW,P.C.,L.L.O.
SUITE 350
9802 NICHOLAS STREET
OMAHA,NE 68114
Designated Office Address
SUITE 350
9802 NICHOLAS STREET
OMAHA,68114
•
Nature of Business
Not Available •
Entity Type •
Domestic LLC
Qualifying State: NE
Date Filed
Aug 18 2014
Filed Documents
Filed documents for 1093R INVESTMENTS,LLC may be available for purchase and downloading by selecting the Purchase Now
button.Your Nebraska.gov account will be charged the indicated amount for each item you view.If no Purchase Now button appears,
please contact Secretary of State's office to request document(s).
Code Document Date Filed Price
CRTO Certificate of Organization Aug 18 2014 $0.90=2 page(s)@$0.45 per • Purchase Now
page _. _......._._
BR Biennial Report Mar 31 2015 $0.45= 1 page(s)@$0.45 per ! purchase Now
page ... ...... _.
• RD Record of Determination Apr 03 2017 $0.45= 1 page(s)@$0.45 per . purchase Now
page . ... ....
BR Biennial Report Apr 05 2017 $0.45= 1 page(s)@$0.45 per Purchase Now
page
Good Standing Documents
• If you need your Certificate of Good Standing Apostilled or Authenticated for use in another country,you must contact the
Nebraska Secretary of State's office directly for information and instructions. Documents obtained from this site cannot be
Apostilled or Authenticated.
https://www.nebraska.gov/sos/ccorp/corpsearch.cgi?acct-number=10196447 1/2
10/15/2018 Nebraska Secretary of State-Corporation and Business Entity Searches
Online Certificate of Good Standing with Electronic Validation
S6.50
This certificate is available for immediate viewing/printing from your desktop.A Verification ID is provided on the
certificate to validate authenticity online at the Secretary of State's website.
Purchase Now
Certificate of Good Standing-USPS Mail Delivery
$10.00
This is a paper certificate mailed to you from the Secretary of State's office within 2-3 business days.
Continue to Order
•
t Back to Top
https://www.nebraska.gov/sos/ccorp/corpsearch.cgi?acct-number=10196447 2/2
NA AC of Intl Jahn A Oala - COIF CATO
IIIHI111111111111111111111111 a
1001297778 Pss: 2
1093R INVESTMENTS, LLC
Filed: 08/10/2014 04:00 PM
STATE of NEBRASKA
LIMITED LIABILITY COMPANY
CERTIFICATE of ORGANIZATION
1093R INVESTMENTS, LLC
FIRST: The name of the limited liability company is 1093R
INVESTMENTS, LLC.
SECOND: The street and mailing address of its designated office in the state
of Nebraska is 9802 Nicholas Street, Suite 350, Omaha,Nebraska 68114.
THIRD: The street and mailing address of its agent for service of process in
the state of Nebraska is 9802 Nicholas Street, Suite 350, Omaha,Nebraska 68114. The
name of its agent for service of process is FORSBERG LAW, P.C., L.L.O.
FOURTH: The personal liability of the members and managers of the
company for monetary damages for breach of fiduciary duty shall be eliminated to the
fullest extent permissible under Nebraska law. The company is authorized to indemnify
its members and managers to the fullest extent permissible under Nebraska law.
•
IN WITNESS WHEREOF, the undersigned has executed this Certificate of
Organization on the date below.
Date: August 14, 2014
LegalZoom.com, Inc., Organizer
By: Cheyenne Moseley, Assistant Secretary
LETTER OF CONSENT
I, George L. Robinson, Chief Executive Officer, of 1093R Investments, LLC, give
full consent/ permission to Legal Zoom for use of the of the name 1093R
Investments, LLC.
George L. Robinson August 07, 2014
Chief, Executive Officer
5416 Ida St.
Omaha, NE 68152
Grown Folks (Social Club)
Business Plan
Business Summary:
The key elements of the Social Club concept are as follows:
A Social and Professional environment. .
Distinctive design features—Grown Folks will be characterized by the elaborate social club
situated in a setting which comfortably accommodates 40 guests. Our goal is to provide a
comfortable and welcoming environment as well as a unique, exciting Social/Business
experience. This social club space will be intended for special events and a private bar would
present an inviting and relaxing atmosphere. The central area of the club will consist of no dance
floor with cocktail seating. There will be no DJ as this is strictly a social environment. A RMS
point-of-sale system will be put into place and will serve as a sales, labor,and liquor/inventory
control system. This system will ensure an accurate, secure,and efficient control over labor
costs, as well as day to day inventory,thus minimizing the possibility of loss or theft.
Exceptional service—In order to reach and maintain a unique image of quality, Grown Folks
will provide a safe and friendly service and atmosphere that will feature security controlled entry
with a high ratio of service personnel to customers and also invest in the training an supervision
of its employees. We estimate 1 service member for every 40 guests.
Grown Folks will also serve as a launching pad for Entreprenaral Chefs that would like to
establish and build their brand by catering their brand of food from 12pm to 6pm on Saturday
and Sunday of each week.
Company Summary:
1093R Investments, LLC is a privately held Corporation.
George L. Robinson will fulfill the role of Owner/Operating Partner of this venture. He is
currently the Chief,Executive Officer 1093R Investments, LLC;, Mr. Robinson's background is
largely within the scope of Business Administration and Event/Project Management. His fields
of expertise will be utilized in this venture via his direct responsibility for the overall business
management structure and personnel. Additionally, he will assume the public relations and
marketing roles for the social club. George's current position is working as a Sales Operations
Analyst at TSYS. George's family has been involved in the restaurant/bar/nightclub scene his
entire life.
If needed, interviews for a bar manager and all other personnel will be conducted by George
Robinson
Page 1 of 2
DEED Inst.a 2018070196,Pg:1 of 2 Rec Date:09/04/2018 13:57:26.407
®Fee Received:516.00 NE Documentary Stamp Tax Fee:S146.25 By:AA
Douglas County,NE Assessor/Register of Deeds DIANE L.BATTIATO
WARRANTY DEED
KNOW ALL MEN BY THESE PRESENTS THAT I or WE,JERRY DEABLER AND DONNA R.DEABLER,
. HUSBAND AND WIFE AND HORACE BETHEA,A SINGLE PERSON
herein called the grantor whether one or more,In consideration of One Dollar and other valuable consideration received from
Stamen
do a by rat n,sell,convey end confirm into GEORGE ROBINSON;+M6 PBRSOOt4 7=WAAfA —'• - .US'
i-ka
vac Twit
herein called the grantee,whether one or more,the following described reel property in DOUGLAS County,NE:
LOT ID, BLOCK 12, PLAINVIEW, AN ADDmON TO THE CITY OF OMAHA,AS SURVEYED, PLATTED,AND
RECORDED IN DOUGLAS COUNTY,NEBRASKA.
To have and to hold die above described premises together with all tenements.hardigmrnts and appurtenmas thereto
belonging unto the grantee end to grantee's heirs and assigns fareverAod the grantor does hereby covenant with the grantee and
with grantee's heirs and assigns that grantor Is lawfully seized of said premises;that they art free from encumbrances eaeept
covenants,easements and resbicaoas of record;all regular taxes sad special assassmeab,except those levied or assessed
subsequent to the date hereof;that grantor her goad right and lawful authority to convey the seine and that grantor warrants
and will defend the title to said premises against the lawful claim of all persons whomsoever.
Dated: 8)221 /0
id1/664•Ce6----t
I Y EABLER HORACE BETIIEA
Eta-to e
DONNA R.DEABLER
STATE OF NU.Ssisalk.HS )
COUNTY OF Cosset V )asThe foregoing instalmentwas acknowledged before me this T/�sra
�' yof 2018 by JERRY
DEABLER AND DONNA IL DEABLER,HUSBAND AND WIFE.
mat comae( Notary Public l a
4.. # ' BYC My Commission Expires 7
e::.nsi/ : Sapienga06,2019
CH
B, 30
http://landmarkwebinternal.douglascounty-ne.gov/Landmark W ebintemal//DOcumenUGetD... 9/12/2018
Page 2 of 2
Inst.#2018070196,Pages:2 of 2
•
•
STATE OF L 1
COUNTY OF 1a5 )a ��
The foregoing instrument was acknowledged before me this G••^aq of Oita U 5F 2018 by HORACE
BEI'NEA,A SINGLE PERSON. J1
Notary Public ea/
Stile of CHRska-Geaeml Notary My commission Fxpirea �/
CNFRYlsion CIY
Em
My Commission Fxp'vea I8-48612
August 78.2P61
•
http://landmarkwebinternal.douglascounty-ne.gov/LandmarkWebintefnal//Document/GetD... 9/12/2018
pg a co co °on
LEASE AGREEMENT
1-01 I�-
This Lease Agreement(this "Agreement)is made this September 01, 2018, by and between GEORGE
• AND TIWANA ROBINSON ("Landlord")and 1093R INVESTMENTS, LLC("Tenant"). Each Landlord and
Tenant may be referred to individually as a "Party"and collectively as the"Parties."
1. Premises. The premises leased is located at 3713 N. 24th Street,Omaha, Nebraska 68110(the
"Premises").
2. Agreement to Lease. Landlord agrees to lease to Tenant and Tenant agrees to lease from
Landlord according to the terms and conditions set forth herein,the Premises.
3. Term. This Agreement will be for a term beginning on September 01, 2018 and ending on
September 30,2088.(the"Term").
( eoye gram/son •
✓levenuo 3iindosv George and Tiwana Robinson 10/01/2018
Landlord Signature Landlord Name Date
NePye ✓to&2n4on,
�/isceznet. cAilnoon 1093R Investments, LLC 10/01/2018
Tenant Signature Tenant Name Date
III II�IIIIIIII�IIIIIIII�IIII
IIIIIIIIIII u�lll�600
1800013000
MANAGER APPLICATION Office Use
INSERT -FORM 3c RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH O C 1 i 5 2018
PO BOX 95046
LINCOLN,NE 68509-5046 NEBRASKA LIQUOR
PHONE:: (402)47!-2814 CONTROL COMMISSION FAX:(402)471-2814 '
Website: www.lcc.nebraska.gov
FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE
PROCESSED
• MANAGER MUST:
• Complete all sections of the application. Be sure it is signed by a member or corporate officer.
corporate officer or member must be an individual on file with the Liquor Control Commission
• Fingerprints are required. See form 147 for further information,read form carefully to avoid delays
in processing, 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 or print document from
Secretary of State website 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,read form carefully to avoid delays
in processing, 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
13ARC{)D1
Form 103
Rev July 2018
Page 1 of 6
MANAGER APPLICATION Office Use RECEIVED
INSERT-FORM 3c
NEBRASKA LIQUOR CONTROL COMMISSION O C ! L 5 201
301 CENTENNIAL MALL SOUTH
Po sox9soa6 NEBRASKA LIQUOR
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 CONTROL COMMISSION
FAX:(402)471-2814
Website: www.lcc.nebraska.gov
MUST BE:
✓ Include copy of US birth certificate,naturalization paper or current US passport
✓ Nebraska resident. Include copy of voter registration card or print out document from Secretary of
State website
✓ Fingerprinted. See form 147 for further information, read form carefully to avoid delays in
processing,this form MUST be included with your application
✓ 21 years of age or older
`Corporation/LLC information.
Name of Corporation/LLC: t ER3l JI\ 5Yf navy'L S 1
!Premise information _.
Liquor License Number: Class Type (if new application leave blank)
Premise Trade Name/DBA: eT,vJt n EC' rKS
Premise Street Address: S1 I3 t
City: ON\al A County: P606)I fi--3 Zip Code: (cZ I I
Premise Phone Number: ( i ) a l(7 oCLt5
Premise Email address: o\to bi\/v 4 3DD /kpl • Cam✓
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. To see authorized officers or members search your license
information here.
•
SI URE RED BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
Rev July 2018
Page 2 of 6
Manager's information must b_eICompleted-bele* ;PLEASE PRINT CLEARLY .
Last Name: . Lvt'"��" /� r First Name: �C rcoe._ MI: L
._J
Home Address: -1!10 "DPI ?�� lJ v�
City: at\ktf) (; County: �4 f}S Zip Code: �5 pL
Home Phone Number: ((�j-6") aRO-1a4 r,
Driver's License Number& State: Ntkrc s ^w
Social Security Number: _ n /
Date Of Birth: _ Place Of Birth: C` "' 1 lAil A) / 'v
Email address: rbk '13c5DE Ad- C&-n-J
• !Are you married?If yes, complete spouse's iriforination(Even if a spousa ffidavit bag begs submitted)
®YES El NO
6pouse's information --
Spouses Last Name: B 1OIW E `Wr
First Name: I la) MI: A.
Social Security Number: •
Driver's License Number& State:_ Arc
Date Of Birth: 1A1 I_ Place Of Birth: \l C
A PLICANT&SPOUSE MUST LIST RESIDENCES)FOR THE PAST'TEN (lo)YEARS ,I
APIPCAN,T _ — .:_.___,, _'_ .SP„OUSE' _ . _ c.. ------
CITY & STATE YEAR YEAR CITY& STATE YEAR YEAR
FROM TO FROM TO
RM
Form 103
Rev July 2018
Pagel of6
WORAP €, , lYIANAGEInta rt3,014Pi,OYERS, - k s
FROM YEAR
TO NAME1 OF EMPLOYER NAME OF SUPERVISOR TELEPHON NUMBER E
( 010 Yfesn .t'r TSY S -SO\ e I Rirt4lite-/3 @per) ( 59 -8LI to
a(930 20c9 PftyPaLk filly cs.K01 .40-5) cola
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,include traffic violations. Also list any charges pending at the time of this application. If more than one party,
please list charges by each individual's name. Commission must be notified of any arrests and/or convictions that may
occur after the date of signing this application.
[N YES ❑ NO
If yes,please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
[� (nun/yyyyy) (City&State) Charge
-R biIhSol) apt co 1 Ik 1\i bit\ ycecLLv ? MCX P1
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
OYES �NO
IF YES,list the name of the premise(s):
3. Do you, as a manager, qualify under Nebraska Liquor Control Act (§53-I31.01) and do you intend to
supervise, in person, the management of the business?
RYES ONO
Form 103
Rev July 2018
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: Tn
Aiw Aix
Date
Applicant Name (mriYY) Name of program(attach copy of course completion
certificate)
•
*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
•
5. Have you enclosed form 147 regarding fingerprints?
ISUYES ONO
Form 103
Rev July 2018
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 §53-131.01)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.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28, CFR, 16.34.
7 et
4Signatere of Manager Applicant Signature of Spouse
•
ACKNOWLEDGEMENT
State of Nebraska County of � las Thhe`foregoing instrument was acknowledged before me this
S eSpiefl/dar-r /datdola
l by JW fjc/ L.NE OF PERSON BEING ACKNOWLEDGED
WLEDGED
AAA.,C-7111 A.A.J v Affix Seal
Notary Pub is signature SARAL HERRI RI L.BRO aeNa
L MyComm.Exp.Sept 15,2020
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 103
Rev July 2018
Page 6 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 §53-131.01)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.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28, CFR, 16.34.
Signature of Manager Applicant Signature of Spouse
ACKNOWLEDGEMENT
•
State of Nebraska
County of Ur) cN tk S The foregoing instrument was acknowledged before me this
917_ /1 by I h wana (Vl Q-0\0\•non
date NAME OF PERSON BEING ACKNOWLEDGED
Affix Seal
No ]rc sign GENERAL NOTARY-Stale of Nebraska
TARA BENAK
My Comm.Eqr.February 3,2020
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 103
Rev July 2018
Pagc 6 of 6
•
PRIVACY ACT STATEMENT/
SUBMISSION OF FINGERPRINTS / RECEIVED
PAYMENT OF FEES TO NSP-CID OCT 1 5 2018
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR
PO BOX 95046 6641915L t5Ir/1rSS1ON
LINCOLN,NE 68509-5046
PHONE: (402)471-2571
FAX: (402)471-2814
Website: www.lcc.nebraska.gov
THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED:
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE
NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE
• Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol;
It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp
Or a check made payable to NSP can be mailed directly to the following address:
***Please indicate on your payment who the payment is for(the name of the person being
fingerprinted) and the payment is for a Liquor License***
The Nebraska State Patrol—CID Division
3800 NW 12'Street
Lincoln,NE 68521
• Fingerprints taken at NSP LIVESCAN 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 may be released to the applicants;
Fingerprint cards should be submitted with the application.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating a
FBI identification record are set forth in Title 28, CFR, 16.34.
Trade Name: & xJ \) HIKE-)Name of Person Bring Fingerprinted: GC-t l L, Rd)
0
Date of Birth:l fast 4 SSN: _Date fingerprints were taken:Q i Lz
Location where fingerprints were taken: C-cle gc.AW
How was payment made to NSP?
VONSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK #
My fingerprints are already on file with the commission —fingerprints completed for a previous
application
le s than 2 years ago?
YES
❑
SIGNATURE RIRED OF PERSON BEING FINGERPRINTED
FORM 147
REV MAY 2018
•
Point-of-Sale Payments Page 1 of I
•
PAYPORT
NEBRASKA.GOV
PURCHASE RECEIPT
Nebraska State Patrol-Criminal Identification Division
3800 NW 12th Street, Suite A
Lincoln NE 68521
(402)479-4971
miranda.erick@nebraska.gov
OTC Local Ref ID: 29414350
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE
Status: APPROVED
Customer Name: 1093R Investments LLC
Type: Visa
Credit Card Number: **** **** **** _.
Total Amount Charged USD$46.38
Items Location Quantity TPE Order Total
•
ID Amount 1p Q�
Liquor License M' 1 31660432 $45.25 �? `
Applicant Name: Tiwana/Robinson hf-�^,.w`,`'�''A'
Date of Birth: C V i 4
Last four of Social Security Number: S
Total remitted to the Nebraska State Patrol - Criminal $45.25
Identification Division cvN,QVSS' I)
hops://otc.edc.nicusa.com/PublicReceipt.aspx?src=csh 10/9/2018
eK-ct
PRIVACY ACT STATEMENT/
Ee �VE�
...11
SUBMISSION OF FINGERPRINTS/
PAYMENT OF FEES TO NSP-CID OCT 1 5 2018
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR
PO BOX 95046 CONTROVMAMISSION
LINCOLN,NE 68509-5046
PHONE: (402)471-2571
FAX: (402)471-2814
Websitc: www.lcc.nebraska.gov
THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED:
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE
NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE
• Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol;
It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp
Or a check made payable to NSP can be mailed directly to the following address:
***Please indicate on your payment who the payment is for(the name of the person being
fingerprinted) and the payment is for a Liquor License***
The Nebraska State Patrol —CID Division
3800 NW 12th Street
Lincoln,NE 68521
•
• Fingerprints taken at NSP LIVESCAN 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 may be released to the applicants;
Fingerprint cards should be submitted with the application.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating a
FBI identification record are set forth in Title 28, CFR, 16.34.
Trade Name: &ate 1'01kS
Name of Person Bring Fingerprinted: Int%! b( Vicew# iW A-VI I Y l t10;(1,')-J
Date of Birth:�. Last 4 SSN: Date fingerprints were taken: Duf{ i Ala
Location where fingerprints were taken: S t PcU\n1
How was payment made to NSP?
MNSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK#
My fingerprints are already on file with the commission —fingerprints completed for a previous
application less than,2 years agy?ThYES O
SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED
FORM 147
REV MAY 2018
Point-of-Sale Payments Page I of I
•
PAYI�ORT
NEBRASKA.GOV
PURCHASE RECEIPT
Nebraska State Patrol-Criminal Identification Division
3800 NW 12th Street, Suite A
Lincoln NE 68521
(402)479-4971
miranda.erick@nebraska.gov •
OTC Local Ref ID: 29414118
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE
Status: APPROVED
Customer Name: George Robinson
Type: Visa
Credit Card Number: **** **** ****
•
Total Amount Charged USD$46.38
•
Items Location Quantity TPE Order Total
ID Amount
Liquor License 1 31659786 $45.25
Applicant Name: George Leon Robinson
Date of Birth:
Last four of Social Security Number: -
Total remitted to the Nebraska State Patrol - Criminal $45.25
Identification Division
•
•
•
•
https://otc.cdc.nicusa.com/PublicReceipt.aspx?src==csh 10/9/2018
11/12/2018 12: 20 FAX e 002/002
•
CITY OF OMAHA
STATEMENT OF BUSINESS ACTIVITY
For
RETAIL LIQUOR LICENSE APPLICANTS
In accordance with Omaha City Municipal Code, Section §15-22, a statement of business
activity must,be submitted to the Omaha City Council by all applicants for retail liquor.licenses, •
This written statement shall describe all types of business or activity that will be operated on the
premises in conjunction with the proposed license. A failure to include a business or activity will
be considered by the City Council as the applicants representation that the omitted business or
activity will not occur on the licensed premises without City Council approval. Failure to operate
consistent with this statement may be grounds for cancellation, revocation, suspension, or non-
renewal of the license (OMC §15-42).
DESCRIBE ALL BUSINESS OR OTHER ACTIVITIES THAT WILL OCCUR ON THE
LICENSED PREMISES.
ThIs establishment will be a social networking and gathering spot for mature Individuals,no IndlvIduale under 21 permitted, There will
not be 6 dance floor nor will there be any dancing, This establishment will serve as a launching pad for entrepreneurial chafe will
Cater their foogln to potentially build a base In order to alert their own establishment. The hours of operations would be
Friday 6:00 o,rrl.•2•00 a m„Saturdays 11.00 a.m.•2:00 a m.end Sundays 11 a.m.2:00 a.m. while this business will focus on the
theft natorl=g their food in alrohol will be served as well Said alcohol shall be beer wine and distilled splits. There wliLbe no
package Ilauor for sale.
•
•
I have read and understand the Good Neighbor.Ordinance (Omaha Municipal Code
Section §18-90 to §18-92.)
1093R Investments, LLC d/b/a Grown Folks
Corporation and/or Trade Name/DB (Please Print)
Na e &Titl o p nt or uthorized Representative •
Grant A, Fors rg, Attorney for pplicant
•
RECEIVED 11-12-' 18 13:05 FROM- TO- Omaha City Clerk P0002/0002
P k�
PUBLIC WORKS DEPARTMENT REPORT ✓�c
DATE: OCTOBER 25, 2018 DUE DATE: NOVEMBER 8,2018
CITY COUNCIL HEARING NOVEMBER 20,2018
APPLICANT: 1093R INVESTMENTS,LLC,DBA "GROWN FOLKS"
LOCATION: 3713 NORTH 24T STREET
REQUESTED LICENSE OR ACTION: CLASS"I"LIQUOR LICENSE
DESIGNATION OF ADJACENT STREET (LOCAL, COLLECTOR,MINOR OR MAJOR
ARTERIAL EXPRESSWAY): rr i nor Z- 1-ev,ctQ
STREET WIDTH AND PROFILE:I-4. - -r)-`/ a fie`i , (k
SPEED LIMIT: rYypi,
AVERAGE DAILY TRAFFIC AND PEDESTRIAN FLOW: .7)67.5e), Ve h=./ v`-
ACCIDENT REPORT AT ADJACENT INTERSECTION:c9`/'-`-''? 4w {-era - S/-✓ E 717
(0407l/4/-/r7/..'>'//10 .a. QC c�4hV-Marti(2 Seh
QCc, .ent5 - a//+/ ,v-FvO'i3/SJt&, Fs- 6 orada,,-317.c,- Pra,+h J-
ca;-).c14 St-re 12f'::;'"'/O r li , /- ✓4' V- &'=417/-)Lre.7)L2f-- 0 Q C'cI dn"Tbs.
POTENTIAL TRAFFIC AND PARKING PROBLEMS: A. M4,
/0 -mod
(A thonature) (Date)
PLANNING DEPARTMENT REPORT
DATE: OCTOBER 25, 2018 DUE DATE: NOVEMBER 6, 2018
CITY COUNCIL HEARING NOVEMBER 20, 2018
LOCATION: 3713 NORTH 24TR STREET
APPLICANT: 1093R INVESTMENTS, LLC, DBA "GROWN FOLKS"
. REQUESTED LICENSE OR ACTION CLASS "I" LIQUOR LICENSES
NEW LOCATION(X)NEW OWNERSHIP ( ) TYPE OF FACILITY: SOCIAL HALL
THIS REQUEST DOES 0 DOES NOT(X) PERTAIN TO AN OUTSIDE AREA(S)
IF SIDEWALK CAFE: R-O-W-LEASE PERMITS OBTAINED
IF OUTSIDE: OUTSIDE AREA IS FEET FROM THE NEAREST RESIDENCE
THIS PROPERTY IS (X ) IS NOT ( ) WITHIN OMAHA'S CORPORATE LIMITS
(If not,do not proceed-Notify the City Clerk's Office and return this form)
********************************************************************************************************
ANNEXATION DATE: ORDINANCE NO. (Only if within last 24 months)
EXISTING ZONING: R7 EXITING LAND USE: RESIDENTIAL
ADJACENT LAND USE AND ZONING:
NORTH: RESIDENTIAL R7
SOUTH: RESIDENTIAL R7
EAST: RESIDENTIAL R5
WEST: RESIDENTIAL R7
PARKING STALLS PROVIDED: ON-STREET
EXISTING USE DOES(X) DOES NOT( )COMPLY WITH ZONING REGULATIONS
PLUMBING FIXTURES PROVIDED: WOMEN'S LOCKED
MEN'S LOCKED
DATE SUBJECT PROPERTY WAS POSTED: 11/07/2018
(Rule#7) DISTANCE OF PROPOSED LICENSE TO ANY SCHOOL,CHURCH,OR CITY PARK: OK
DISTANCE OF PROPOSED LICENSE TO ANY EXISTING LICENSE: OK
(State Law) DISTANCE OF PROPOSED LICENSE TO ANY CHURCH OK
SCHOOL OK HOSPITAL OK HOME FOR THE AGED,INDIGENT
OR VETERANS OK COLLEGE OR UNIVERSITY OK
z Zej77egrA «/49
(Authorized Signature) (Date)
0 flHA, N
City of Omaha, Nebraska �� i:/1,,
wfreiti�x 6`�s
1819 Farnam — Suite LC 1 z p� c 'r,s,
n�b�' [ �I
Omaha, Nebraska 68183-0112 r:'
grez-
Elizabeth Butler (402) 444-5550 ae
City Clerk FAX (402) 444-5263 4'TEo PEE
November 6, 2018
1093R Investments, LLC Application for a Class "I" Liquor License
Dba"Grown Folks"
3713 North 24th Street
Omaha,NE 68111
Dear Liquor License Applicant:
•
This letter is notification that a hearing before the Omaha City Council on your application for
liquor license has been set for November 20, 2018 . The City Council Meeting begins
at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic Center, 1819 Famam
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,
Elizabeth Butler
City Clerk
EB:clj
City of Omaha, Ne6raska �� 1 43.4,
cp
1819 Farnam —Suite LC 1 z it i? Ai
Omaha, Nebraska 68183-0112 nr.r1t( m
Elizabeth Butler (402) 444-5550 ry•
City Clerk FAX (402) 444-5263 o92'Eo FSB09P4�
November 6, 2018
1093R Investments, LLC Application for a Class "I" Liquor License
Attn: George L. Robinson for 1093R Investments, LLC, dba"Grown
5416 Ida Street Folks", 3713 North 24th Street
Omaha,NE 68152
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application for
liquor license has been set for November 20, 2018 . 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.
•
Ordinance No. 37046, passed June 27, 2005, requires each applicant to submit a written
statement describing all types of business or activities that will be operated on the premises in
conjunction with the proposed license. Attached is the MANDATORY statement that must
be signed and returned (hand deliver, mail or fax) to the City Clerk's Office 7 days in
advance of the public hearing.
Sincerely yours,
Elizabeth Butler
City Clerk
EB:clj
City of Omaha, Nebraska °M„HA, N
1819 Farnam — Suite LC 1 iMal '�r'%s
Omaha, Nebraska 681 83-01 1 2 ngrr., roil
Elizabeth Butler (402) 444-5550 ?.4 ro.
, City Clerk FAX (402) 444-5263 OED FEBRUP``4
November 6, 2018
Grant Forsberg, Attorney Application for a Class "I" Liquor License
Forsberg Law for 1093R Investments, LLC, dba"Grown
9802 Nicholas Street, Suite 350 Folks", 3713 North 24th Street
Omaha,NE 68114
Dear Liquor License Applicant's Attorney:
This letter is notification that a hearing before the Omaha City Council on your application
for liquor license has been set for November 20, 2018 . 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.
Ordinance No. 37046, passed June 27, 2005, requires each applicant to submit a written
statement describing all types of business or activities that will be operated on the premises in
conjunction with the proposed license. Attached is the MANDATORY statement that must
be signed and returned (hand deliver, mail or fax) to the City Clerk's Office 7 days in
advance of the public hearing.
Sincerely yours,
Elizabeth Butler
City Clerk
• EB:clj
OtAAHA• N
City of Omaha, Nebraska v 9N
ei1819 Farnam — Suite LC 1 z a'� p '�t
Omaha, Nebraska 68183-0112 ® ,�L � ,
Elizabeth Butler (402) 444-5550 PA ry-
City Clerk FAX (402)444-5263 O'i'ED FEBRVP¢�
NOVEMBER 9, 2018 /p2� /V O'% 4 C Ps
NOTICE OF REQUEST: To consider a CLASS "I" LIQUOR LICENSE
APPLICATION which allows the sale of beer, wine and distilled spirits, by the drink
on the premises only.
APPLICANT: 1093R INVESTMENTS, LLC
DBA GROWN FOLKS
LOCATION: 3713 NORTH 241" STREET
As an owner of property within 500 feet of the above referenced location, you are
being notified that the Omaha City Council will hold a meeting and public hearing
on this request on Tuesday, NOVEMBER 20, 2018 in the Legislative Chambers —
Level LC of the Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha,
Nebraska. The meeting begins at 2:00 PM.
A notice of this meeting published in the Daily Record NOVEMBER 12, 2018 .
Anyone interested in the actions of the Omaha City- Council should be in
attendance. To obtain additional information or to submit written testimony, please
contact Carman Johnson at 402-444-5324 or carman.lohnson(cr�citvofomaha.orq.
ALL REQUESTS FOR SIGN LANGUAGE INTERPRETERS (SIGNERS) WILL REQUIRE A
MINIMUM OF 48 HOURS ADVANCE NOTICE. IF ALTERNATIVE FORMATS ARE NEEDED,
ALL REQUESTS WILL REQUIRE A MINIMUM OF 72 HOURS ADVANCE NOTICE.
PLEASE NOTIFY ELIZABETH BUTLER, (402) 444-5557, IF ARRANGEMENTS NEED TO BE
MADE.
E-MAILED TO NLCC: ,2 I- IV
RECOMMENDATION OF THE NEBRASKA LIQUOR CONTROL COMMISSION
Date Mailed from1Commission Office: October 19, 2018 tb
I, Kimberly Pulliam Deputy Clerk of The City of Omaha,A Municipal Corporation
(City,Village or County)
Nebraska, hereby report to the Nebraska Liquor Control Commission in accordance with Revised Statutes of Nebraska,
Chapter 53, Sec 134(7)the recommendation of said city, village or county,as the case may be relative to the application for
a license under the provisions of the Nebraska Liquor Control Act as applied for by:
1093R INVESTMENTS LLC dba GROWN FOLKS
3713 N 24TH STREET, OMAHA Nebraska 68111 (DOUGLAS County)
NEW APPLICATION for Class I-122838
45 days — 12-03-2018
1. Notice of local hearing was published in a legal newspaper in or of general circulation in city,village or county,
one time not less than 7 nor more than 14 days before time of hearing.
Check one Yes X No
The Statutes require that such hearing shall be held not more than 45 days after the date of receipt of this notice
from the Commission.
2. Local hearing was held not more than 45 days after receipt of notice from the Nebraska Liquor Control Commission.
Check one • Yes X No
3. Date of hearing of Governing Body: November 20,2018
4. Type or write the Motion as voted upon by the Governing Body. If additional Motions are made by the Governing
Body,then use an additional page and follow same format.
MOTION TO GRANT
5. Motion was made by: Aimee Melton Seconded by: Ben G.Gray
6. Roll Call Vote: 6-1 Nay: Jerram
7. Check one: The motion passed: X The motion failed:
8. If the motion is for recommendation of denial of the applicant,then list the reasons of the governing body upon
which the motion was made.
•
(Attach additional page
if necessary) 'J Q
SIGN HERE DATE I1/2 p
Deputy Cle si ature