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RES 2015-0372 - Appoint Steven E Williams manager of Bag N Save #781 g4.vtTE 1 \\\ 1 o . rF�4 y. it g. i' `` E STATE OF NEBRASKA ..�,/ u , . s Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION u N " .'= Governor A�{ Q Hobert B. Rupe 2015 MAR -9 i 41 J: 39 Executive Director IIII\\�`�,,� ..--- 301 Centennial Mall South, 5th Floor P.O. Box 95046 CITY C LE R K Lincoln, Nebraska 68509-5046 Q A Phone(402)471-2571 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 LICENSE ••C-98092, #r -98093, #C-98094, #C-98096 Dear Clerk: Enclose I copy of a manager application for Steven E. Williams, in connection with the Bag N Save stores 781, #785, #784, and #774, 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, t f ., ,e_)qc-cin-cerl_. 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 Primed with soy ink on recycled paper MANAGER APPLICATION Office Use INSERT -FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION RECEIVED 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 FEB 10 2015 PHONE: (402)471-2571 FAX:(402)471-2814 NEBRASKA LIQUOR Website:www.lcc.ne.gov CONTROL COMMISSION 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 Corporation7LLC information Name of Corporation/LLC: `} e- :,(3)5 .--�- Premise information Liquor License Number: oq O 0 12N. Class Type C- (if new application leave blank) Premise Trade Name/DBA: '61 81 Premise Street Address: t S3-1 0 .c S it City: 0 -V — County: ()a� 5 Zip Code:(0g 13 Premise Phone Number: LIOa_cat.l- 6,8v 0 Email address: Npvtcn, ,n1 Aft @ The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed wit the Commission. Click on this link to see authorized individuals. http://www.lcc.ne.gov/lice e search/licsearch.cgi 7277.- - VAA-V-A-CCIA WW/v.i\e__LA V e\ SIGNATURE UIRED BY CORPORATE OFFICER MANAGING MEMBER (Faxed signatures are acceptable) 1111110101111111110 Form 103 REV JAN 2015 Paee 2 of 6 1500004048 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: vOi t--1,k 0 M 5 First Name: ct-1:-J MI: Home Address (include PO Box if applicable): 111? 6,`3Q° A Je.. City: tam q rtA County: G I S Zip Code: 6 t 30 Home Phone Number: 404 _ Business Phone Number: 40 Z- Social Security Number.—— _ _ _ Drivers License Number& State: �F t Date Of Birth: Place Of Birth: �t OLtX Email address: s{WPJ 2 . •1 i L i, S Se,37_-1-.a"J,n/As-4 co nn Are you married? If yes, complete spouse's information(Even if a spousal affidavit has been submitted) YES ❑NO Spouse's information Spouses Last Name: (J)tL--tA/5 First Name: ��vfr c4 MI: g Social Security Number: Drivers License Number& State: _ _ 4EgaiSeA Date Of Birth: . T Place Of Birth: 1��t� liJc�E AdigiggAssi.A APPLICANT& SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS APPLICANT SPOUSE CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR FROM TO FROM TO OAN ALAA f p1CGa►s+tA age Lrror RECEIVE) 201 a ,QA, LIQUOR 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 900 I O4trr1r SP,v2sh.J UASi :fv14(az c*i goL-53 --e/-00 pro 200i Y S...,p ou L wre (-Z-5 2..-i35 6442 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non- participation. Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge. Charge means any charge alleging a felony, misdemeanor,violation of a federal or state law;a violation of a local law, ordinance or resolution. List the nature of the charge, where the charge occurred and the year and month of the conviction or plea. Also list any charges pending at the time of this application. I e pry , please list charges by each individual's name. V YES ❑ NO FEB 1 0 2015 If yes,please explain below or attach a separate page. NEBRASKA LIQUOR CONTROL COMMISSION Date of Where Descnption Name of Applicant Conviction Convicted of Disposition (mm/yyyy) (City& State) Charge GSS t C4 W LLL<►AIS (' ,ge4 227_ Cs:'r 4m4,, FAt4.420 SzO it)o 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? J JYES ONO ,)PIA c-1"; 4/.,� i-t<S&c- L,, :.4, e,i3. 2'6 IF YES, list the name of the premise(s): C Gc A1,4a7"; c.1 S. I L.,,ocoLA); 66S-Z 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? OYES v 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 009VI US Name on Certificate: �sEd 2A3 .S Applicant Name ( tyYyy) Name of program(attach copy of course completion certificate) J V✓i“-ofai s 0; /0013 l`S S I e0 %.4--4 -o f�.�(/ � . ©'. ( �c,�3 OC°(.--A) S0 e SjtJ�� Wlt.-c..A[hS KO c +AL-. *For list of NLCC Certified Training Programs see www.lcc.ne.gov/traininginfo.html Experience: Applicant Name/Job Title Date of Employment: Name&Location of Business: Assr- �...taLA-.,0"5 /11�.)Ac,- 15/51v-ao0{ 1 -c S ar,►ow 7$ nwi JE. ✓f WJE WftC��ar+� /52r D.2.ec uk2 - erAr 4}1154 " AA 7-7 - (4,4)CvLw1 STeo60) } Aar-Sutler✓ OCA-C.,Mcnr- P-1"43,4f45'rt Om/At-1/4A, 5. Have you enclosed Form 147 regarding fingerprints? ENO REC' NE VBB �15 QUOR Lk Form 103 REV JAN 2015 Page 5 of 6 PERSONAL OATH AND CONSENT OF INVESTIGATION The above individual(s), being first duly sworn upon oath, deposes and states that the undersigned is the applicant and/or spouse of applicant who makes the above and foregoing application that said application has been read and that the contents thereof and all statements contained therein are true. If any false statement is made in any part of this application, the applicant(s) shall be deemed guilty of perjury and subject to penalties provided by law. (Sec §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 i ..;j.lete, inaccurate, or fraudulent. REC FEB 1 2,1,(2 LIQUOR �i5 NEBRINSKr0 1SSION Signature of Manager Applicant vkittakieCkSpouse ACKNO WLEDGE1VlENT State of Nebrask County of ,b p u 9 bra- The foregoing instrument was acknowledged before me this �Alukity 2 ZD/5' by 3kv�. LJ/ b/A1�,5 da e' name of person acknowledged Affix Seal N. .ry ' b lc signature CAROLYN D.STRICKLAND t°En'AI 1 MY COMMISSION EXPIRES NOTAP . August 5,2016 h ,a 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 IAN 2015 Page 6 of 6 IPrint Form_. J SPOUSAL AFFIDAVIT OF Office Use RECEIVED NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION FEB 1 0 2015 301 CENTENNIAL MALL SOUTH PO BOX 95046 OE(0) i25 �a6 � A LIQUOR Q J O RxN : 4247 257 FAX:(402)471-2814 CONTROL COMMISSION 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 053-125(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 cess this application. i, signature of spouse asking fo -- aiver Printed name of spouse asking for wai er ( pouse of individual listed below State of br.5ka. )3J22 County of loLgil ,,,, The forego' : ' strument was acknowledged before me this f _ • by 2f j ■r r . 1 date name of person. , owledged L�`� 1 :t Affix Seal ` * GENERAL NOTARY-Slake of Nebraska Notary Public i e USA L HOFFMAN e �— My Comm.Exp.Sept 19,2013 .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 in:. cane- or revoke the liquor license. ir ---eug,. 6,D i t-L-, 4- Si e o nidividual involved with application Printed name of applying individual (Spouse of individual listed above) State of / ` ' JCounty of A-s-- The foregoing instrument was acknowledged before me this — LG , Z4 z/1/,� by 0k e..�F'M / // 6 date ,mhname of person acknowledged ! ��'1 ltA�'_ Affix Seal . y. blic: 16 � 44 CAROLYN D.STRICKLAND i 1 of : :- MY COMMISSION EXPIRES 11 NOTARY:t` *l ' August 5,2016 In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons utsat lt�cl,. A ten day advance period is requested in writing to produce the alternate format. FORM 35-417S Revised I/2008 Print Form SPOUSAL AFFIDAVIT OF I 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. r \C_ 'St Cca � Ian') Si nature of spouse asking for waiver Printed name of spouse asking for waiver (S ouse of individual listed below) State of County of The foregoing instrument was acknowledged before me this by S ScaDLA Vte name of person acknowledged V0 /r�(1i Affix Seal /111 ! IXINEM.g ARY-Shied Iamb Notary Pub is signature *Cain 80.Omar 1St= KFitS1iNA 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 F in:c :r,rcrson acknowledged 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 AP iii CO `QO L.....irgiqr--N,..___Alt_ _frif- , rA kl E. CD cci —h gi k.ei o 0_ � t y m E. o = le-Si _ o � 2 r N 4 N i Z � 16)N co °o o °' • - 4:. ' 0 r.) ircl 3 a -c) t"111 a.- r4"". : 0 0 o m 114.14 Co r1/4- ft.. ' 0 a) pia H, 69 L) 0 12:if , 9 La ck Fc \a ON N GOB dlif -i ;o tii CO 5' En n 0 g tVe1.0, N 45C002R/fULF -Te4 N __," 0 is, ,z4- F: L41Crkl --t ik' , 0 %� VJi 0 2 0 1 ° m o ro (Di CD 4 2 ii,,,..7 ! ,7-2/151 CD 11 o o O mtIll L.'S o Z1; k._,NO rp o m :61 ii 4 3 0) o CI c 9_ ft tftft4 0 10 (D ig to co : 0 fq g I-1; Td) ID 6,1)"- 0 s. �, 0 0 kelt •741-re- 6-- or- 67- or- oi-ri74 A Or,„...) 0.' 0. Oigfiti. _ -€:...t.i`- )...6.) urVk pa���O colt-c City O ® � ebrasa MAHA �, ma ��° ��� 1819 Farnam —Suite LC 1 z ' � � ,r� dt Omaha, Nebraska 681 83-01 1 2 H fall Buster Brown ° y g�'�!•. —rz - (402) 444-5550 = ,v, City Clerk FAX (402) 444-5263 00 RTED FEBRt'' March 17, 2015 U Save Foods, Inc. Application to appoint Steven E. Williams Dba"Bag N Save#781" manager of your present Class "C" Liquor 15370 Weir Street Liquor License location Omaha,NE 68137 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 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, Buster Brown City Clerk BJB:clj City of Omaha, Nebraska oMAHq �, v 1819 Farnam — Suite LC 1 z �� '� Omaha, Nebraska 681 83-01 1 2 �54 ���„ 1 Buster Brown (402) 444-5550 �'o�:7- �: t �' �' ,� City Clerk FAX (402) 444-5263 0 4�ti 9TFD FE100 March 17, 2015 Steven E. Williams Application to be appointed manager of the 1417 South 163rd 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 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, 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. �2 U Save Foods, Inc., dba "Bag N Save #781", 15370 Weir 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 9