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RES 2015-0371 - Appoint Steven E Williams manager of Bag N Save #780 �0��xATF' ,, vSTATE OF NEBRASKA it: - z 4 lr EDIV Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION '17 '/ Governor Hobert B. Rupe Executive Director t,t```s-to j86� 20 MAR+ - 301 Centennial Mall South,5th Floor P.O.Box 95046 Lincoln,Nebraska 68509-5046 CITY CLERK Phone(402)471-2571 M A HA. NE B R A S K +, Fax(402)471-2814 or(402)471-2374 TRS USER 800 833-7352(TTY) February 26, 2015 web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Steven E. Williams LICENS• #C-9808. #C-98086, #C-98091 Dear Clerk: Enclose.— . copy of a manager application for Steven E. Williams, in connection with the Bag N Save stores '•786 #776, and #779 all 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, 2_E—WedAL-rr-LeJ7 Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION 402-471-2571 encl. Janice M. Wiebusch Robert Batt Bruce Bailey Commissioner Chairman Commissioner An Equal Opportunity Employer Printed with sots ink on recycled paper MANAGER APPLICATION Office Use INSERT -FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH FEB 1 0 2015 PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 ���RAJ1��M� ���� FAX:(402)471-2814 CONTRO(....G{� R Website: www.lcc.ne.gov MUST BE: R ✓ Citizen of the United States. Include copy of US birth certificate, naturalization paper or current US passport ✓ Nebraska resident. Include copy of voter registration in the State of Nebraska ✓ Fingerprinted. See Form 147 for further information, this form MUST be included with your application. ✓ 21 years of age or older Corporation/LI.0 information Name of Corporation/LLC: V S&i,c.. Premise';:infoiimation Liquor License Number: Oct 0 S S Class Type C (if new application leave blank) Premise Trade Name/DBA: N SSG -IA--1& Premise Street Address: 6 6-0 M. l 0 City: 0 mA-V\& County: 1/4•145 Zip Code: (2$13 9 Premise Phone Number: y 0 2—3 9 0 — 6 9 9 0 Email address: I vct n cry, tom;en\a4.,` 9 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://wvvw.lcc.ne.gov/lice/Se search/licsearch.cgi r/ % -- k<AA 1n1 e c r `v . ,IA.r\c. V P\�je c Cc- -mr, 7QUY SIGNAT D BY CORPORATE OFFICER/MANAGING MEMBER (Faxed signatures are acceptable) 11111111111111111111 Form 103 REV JAN 2015 1500004202 Page 2 of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: V -l1-L-<onti 5 First Name: crc-t.) MI: C Home Address (include PO Box if applicable): ('\ (7 Sa r 63913 Ave- City: £mA rtA County: . o-LA S Zip Code: Cain(3 0 Home Phone Number: 402 Business Phone Number: ` 02--6135 -ere)sa Social Security Number: Drivers License Number& State: urn Date Of Birth: Place Of Birth: St otx C►� ocq Email address: S• e • • LA M S 't Se6l-t-rAn-AAS co M Are you married? If yes,complete spouse'sTinformat on(Even if a spousal affidavit has been submitted) YES ❑NO Spouse's information -`` Spouses Last Name: Wkti-►-eAnv+s First Name: __ c�a MI: Social Security Number: Drivers License Number& State /1 a9AseA Date Of Birth: Place Of Birth: 41-r-gOIA £ /)eg(ASZA APPLICANT 'OUSE MUST.LIST S WW( FOR THE PAST TEN 1Q =b' „ CITY & STATE YEAR YEAR CITY & STATE YEAR YEAR FROM TO FROM TO OnA r PI,CG(SKA 19gS Lrrz,..i RECEIVED c'r. 10 CONTROL CO M 8 ICN Form 103 REV JAN 2015 Page 3 of 6 MANAGER'S LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 'CPO Zoo+ ( , gv.Qen,ra(L Lev.w 1102.-135-104,42_ l. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non- participation. Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge. Charge means any charge alleging a felony, misdemeanor,violation of a federal or state law; a violation of a local law, ordinance or resolution. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. If more than one party, please list charges by each individual's name. YES ❑ 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 RAIL. RECEIVED FEB 1 o ZO 5 NEBRASKA LQUOR �( 2. Have you or your spouse ever been approved or made app a01-lqa l §ss/i2n Nebraska or any other state? t NYES ENO IF YES, list the name of the premise(s): C - / J 1,�t�Mh`Z+ ICI S S. 17 L-voca,_n1 J 2 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? DYES NO Form 103 REV JAN 2015 Page 4 of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued: k-000"ob Name on Certificate: 5TEOGA3 (•�{1�c,ut/bts Applicant Name Date Name of program(attach copy of course completion certificate) (mm/YYYY) (,Jtt,(4.4M3 c 7 /9013 ' d ( ‘w,A3 621 old L3 LOC°t--,J 50 t1502-,tom *For list of NLCC Certified Training Programs see www.lcc.ne.gov/traininginfo.html Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: gs 5 Jrrz-biL "$ /nLZ- 2 /5/0-9oo( e4 Ea-S stie.rn, L S (f)not", .4)E. S7��G��(�t. or�5 I�CC�� �✓a�� ocAtA ..rr.i` ©/WttkA 5. Have you enclosed Form 147 regarding fingerprints? _ B P t [AYES (-NO LIQUOR CONNETROL C0MM1 v!ON Form 103 REV JAN 2015 Page 5 of 6 PERSONAL OATH AND CONSENT OF.JN STIGATION 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. Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebrask County of p (.(,q 1 i — The foregoing instrument was acknowledged before me this /%1 4-12-9 2/ 2 D/5- by Sk V L 6)/ /1/A- 11 da e' name of person acknow edged Affix Seal ry is signature '" ,l tiN CAROLYN D.STRICKLAND .Cr"""`=.= MY COMMISSION EXPIRES s NOTARYfr August 5,2016 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. fr-f-TIVEn TL Form 103 TROL COd'11 1T e sly REVPage 6of6 , Print Form SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION LNSERT NEBRASKA LIQUOR CONTROL COMMISSION RECEIVED 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 F E u g 9 2015 PHONE:(402)471-2571 VlJe6site: wuw.lcc.ne.eov NEBRASKA UOfi OONTROA_ C0 � � R I acknowledge that I am the spouse of a liquor license holder My signature below confirms t at w1 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 applicationel lb.. _al kft...— . ..• ,di A ,4..\-eSt cf :iLII tvtoos 'ignature of spouse asking . :'ver 'tinted name of spouse asking for waiver i pouse of individual listed below) State of ,;ejor43 lc,.. County of 1,,,, ,,,, The forego : ' strument was acknowledged before me this by 4( 1 i a i date name of person an s wledged I { Affix Seal .2M.. \,. 1;1tin fradri G�RAL NOTARY-State of Nebraska , `Notary Public re LISA L HOFFMAN ,,,v My Comm.Exp.Sept 19,2919 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 053-125(13))the Comm ion m cane or revoke the liquor license .----F?::(S- 0 i i-L—t_4/14' Si e o individual involved with application Printed name of applying individual (Spouse of individual listed above) State of f V ) 1 -_tt County of .---LI-11-424-S---- / The foregoing instrument was acknowledged before me this —i-A(1 Z 4 2 0,6' by O`V Y iii/ /// 6 mitts-of pets,/1 ac),n sdacd — I Affix Seal D 7-1 Not a blic 'gn e $::t STRICKLAND CAROLYN D.S D .:"..., `_.i MY COMMISSION EXPIRES i. : :noTurrr In compliance with the ADA,this spousal affidavit of non participation is available in other formats forlpersotss Wruftusamlh'fe3' r t"'" '-" -- A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 112008 Print Form SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX:(402)471-2814 Website: www,lcc.ne.gov I acknowledge that I am the spouse of a liquor license holder My signature below confirms that I will have not have any interest,directly or indirectly in the operation or profit of the business(§53-125(13))of the Liquor Control Act. I will not tend bar,make sales,serve patrons,stock shelves,write checks,sign invoices or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity I understand my fingerprint will not be required; however,I am obligated to sign and disclose any information on all applications needed to process this application. ,\2JS--.t caLitpi i c{ry) S Si nature of spouse asking for waiver Printed name of spouse asking for waiver (S ouse of individual listed below) State of e\O 01... County of _ The foregoing instrument was acknowledged before me this by .� ate name of person acknowledged Affix Seal No1w•$t�1� Ii11ka1 Notary Pub tc signature KRISTINA POSTI.EINAI?' MktCam►Bp.Dicerdirl 201! 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 Signature of individual involved with application Printed name of applying individual (Spouse of individual listed above) State of __-- County of _ The foregoing instrument was acknowledged before me this _ — — by naanc of pci soa..cknowl t dged Affix Seal Notary Public signature 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 CO4010 9-3 5 U1 `2 O t 0 Pr..j 0 kti 0 ) )1/4 m r0 t V c x irq ti3 FIT m ci _, CD 52 ‘Iiiiii.t CI) 0 D Cfl w c Cr) Q 0 ti.,,, 0 oo o ,, v Q. Z S et 0 16) CDT i3 0 et C,) k..;\0 6 > (f1*t. 0 • 0 CA FEB 1 0 Z0 5 NEBRASKA LIQUOR CONTROL COMMISSION N *1110 -i XI ST) 03 5 Cn 5 —I rao =0 ....., ...., .._.... ._ s 2/ CD 0 cT) CA ) 71 67 91 ) 7) cd"), 7) —t) 7) 9.1 o 7) 0 ) 7) ._ -o gi' CI) . () CI cie'l 7) 71 i 7 xm = i..._, g- M : 71 ) (D --1 5n 3 5- L71 o f4 i < co lisii. ' 7) 5..") 6 r- z c ttai c4 Z 4) CI g l't 71 A) -1 . 0 T n r b 5i-9 4; ./..) r.,?) a h'fti gi fit :7) 5,) ) 3 c) -0 LT"'"I o'-___ 7tt• 7%) 9"1 o 0) CD h*ANI 5 2) 91 74: ) a 7:1 EST; ill 5:71 ) (1) ID a C,1 cn et 7) 7) 5.7) ) P 1 1 i, ) , , 71 7.) ) 7) rde") ry,) 7) cl 7) ,1 . i -- -- ......) ......N..)....1,,) or'../ ':-P3 c:iON CONTROL :i3-tfKcAolviLliNiaiitisc,i)P. City ofOmaha, fNthrasIa oFoMAHArN�B4, 1819 Farnam — Suite LC 1 17� 1140 '�r' sit Omaha, Nebraska 681 83-01 1 2 � ,,r "i, Buster Brown o`, �} ',� 4 (402) 444-5550 ��` - r ry, City Clerk FAX (402) 444-5263 o 9T4'D FEI30' March 17, 2015 U Save Foods, Inc. Application to appoint Steven E. Williams Dba"Bag N Save#780" manager of your present Class "C" Liquor 2650 North 90th Street Liquor License location Omaha,NE 68134 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 March 31, 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, z‘t6 Buster Brown City Clerk BJB:clj �r1iAHA, N ('ity ofOmaFta W o4 �� 1819 Farnam — Suite LC 1 z w pots i Omaha, Nebraska 68183-0112 0gr ,.v' ;Ao Buster Brown (402) 444-5550 k City Clerk FAX (402) 444-5263 o " ' 9 � RTtb FE1303' March 17, 2015 Steven E. Williams Application to be appointed manager of the 1417 South 163`d Avenue present Class "C" Liquor License locations Omaha,NE 68130 for U Save Foods, Inc. —see attached list 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 March 31, 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 U SAVE FOODS, INC 5110 SOUTH 108TH STREET 68137 DBA BAG N SAVE#774 U SAVE FOODS, INC 5019 GROVER STREET 68108 DBA BAG N SAVE#779 U SAVE FOODS, INC 2650 NORTH 90TH STREET 68114 DBA BAG N SAVE#780 U SAVE FOODS, INC 15370 WEIR STREET 68106 DBA BAG N SAVE#781 U SAVE FOODS, INC 14444 WEST CENTER ROAD 68137 DBA BAG N SAVE#784 U SAVE FOODS, INC 3003 NORTH 108TH STREET 68154 DBA BAG N SAVE#785 U SAVE FOODS, INC 8005 BLONDO STREET 68144 DBA NO FRILLS SUPERMARKET#789 U SAVE FOODS, INC 3548 "Q" STREET 68164 DBA NO FRILLS SUPERMARKET#793 U SAVE FOODS, INC 7402 NORTH 30TH STREET 68134 DBA NO FRILLS SUPERMARKET#795 U SAVE FOODS, INC 820 N SADDLE CREEK ROAD 68107 DBA NO FRILLS SUPERMARKET#797 U SAVE FOODS, INC 3026 SOUTH 24TH STREET 68112 DBA NO FRILLS SUPERMARKET#800 U SAVE FOODS, INC 4240 SOUTH 50TH STREET 68132 DBA NO FRILLS SUPERMARKET#802 U SAVE FOODS, INC 13215 WEST CENTER ROAD 68108 DBA NO FRILLS SUPERMARKET#805 No. :.-3 7/ U Save Foods, Inc., dba "Bag N Save #780", 2650 North 90th Street, requests permission to appoint Steven E. Williams manager of their present Class "C" Liquor License location. 03-31-15;cj RECEIVED Presented to Council: March 31, 2015 - Approved 7-0 Buster Brown City Clerk