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RES 2015-0374- Appoint Steven E Williams manager of Bag N Save #785 �-.�1{E ST9r% r p a4lly Ct, F NED STATE OF NEBRASKA w r% Y y Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION a Governor p��q n� Hobert B. Rupe taikor'A lilt, 4, ' fs!i 7' 39 Executive Director �� 301 Centennial Mall South,5th Floor P.O.Box 95046 C i T,(, CLERK Lincoln,Nebraska 68509-5046 n? A'H L, N E B R A S K 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.Icc.ne.gov/ OMAHA CITY CLERK _ 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Steven E. Williams LICENSE #C-98092, C-98093 C-98094, #C-98096 Dear Clerk: Enclosed is a c 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, 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 soy ink on recycled paper MANAGER APPLICATION Office Use INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 RECEIVED PHONE: (402)471-2571 FAX:(402)471-2814 Website: www.icc.ne.gov FcB 01 MUST BE: NEBRASKA LIQUOR ION ✓ Citizen of the United States. Include copy of US birth ce i> � ion� papa or n ((- 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/LLC information _ . ;: _ e._. ,.:_ Name of Corporation/LLC: U �e. A5 . 1,,Nc__ Premise,information Liquor License Number: CSC}i b`1,?j Class Type C.-- (if new application leave blank) Premise Trade Name/DBA: ) N cJc- 1%6- Premise Street Address: 306 3 N. t t% c e f— City: 6 r hA- County: ' G n\aS Zip Code:Co8 I b`( Premise Phone Number: L(U , -"Pt-2 -S'S 3 Email address: No.,,,c,N . KV M\ja @d Sri" A v\a \'`, co rr\ The individual whose name 's listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed ith the Commission. Click on this link to see authorized individuals. http://www.lcc.ne.gov/license search/licsearch.cgi -- V,AR Vex n r\N, Y11,\.,,o ne.` i U CI 1 Se uc- r SIGNATU REQUIRED BY CORPORATE OFFICER/ MANAGING MEMBER (Faxed signatures are acceptable) Form 103 REV JAN 2015 Pale 2of6 1500004049 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: GO{ fJ rn 5 First Name: i>vc �c,� MI: E Home Address (include PO Box if applicable): IL\17 co-, I tsiS2" /J JG. City: £IM ttA County: . C S Zip Code: Ci✓'a(3 0 Home Phone Number: 401 ' /79- Business Phone Number: 40 Z' 3`J-6,`�5 Social Security Number.. Drivers License Number& State: . itilekstt./ Date Of Birth: . Place Of Birth: I 014X Cii 7 Email address: CA-e4 2 .(J•11 t.a M i SeAR.Y.44VAS C a cm Are you married? If yes, complete spouse's information(Even if a spousal affidavit has been submitted) BYES ❑NO Spouse's information Spouses Last Name: (.Ntt.-4---:.s 0ny First Name: Secs(C.4 MI: g Social Security Number: Drivers License Number& State: 4 :?r;ji'A Date Of Birth: f; Place Of Birth: gt�lr t.hu 1= A)eg(L;aSKy 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 Orroi-kA , C;f3(1-86A • REC INS „AmtisSI1/4., cOpit 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 9ooi lGdreAT SPAait+aA)As+ (V14fal. 6,2.,r-Ftn/ qOL-5537-4,6o0 rich) -2coi ( ►, La-wie -S 1102.-q3s-6,41-E2_ 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. If more than Que_prittfse list charges by each individual's name. RECE 14 YES ❑ NO FEB 1 0 2015 If yes,please explain below or attach a separate page. NEBRASKA LIQUOR Date of Where Description CONTROL COMMISSIOR Name of Applicant Conviction Convicted of Disposition (mm/yyyy) (City& State) Charge (AL AA'►c *'13 Zc AkINAS4A SPSFa 0— C;.4,�-r1 -SSie u-c iMS fito e.tk axrz. ayitvt,sk F,4,42e ;a �zo !vQ 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? ]YES ONO cZ -&c- L ti U-ter; ;J£ IF YES, list the name of the premise(s): C _ /// 02 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? OYES , 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: H6'000VIC... Name on Certificate: 5-1-6..)2,0 Applicant Name Date Name of program(attach copy of course completion certificate) (m/YYYY) t1 biiLC.cea, is 0 / °13 1.Zn ‘ S k CJ r (,� oLK4 4 Arts 62 1 di t3 LA)Co(-A) 50 e-(c0?-1)E2.- ST1 J Wi►.�.Ar.5 Les.rc.), .; ao$t-rpc-tr3 CoutA)44 *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: Qxcr 5ci r7-.61-(- 0,1.s //YIAAM&-err.. 15. 0-?oot e.h;401-S , E W1 AMy /5raeD.2ce ta- atX>I a, -( .0,05 { - MA ^ 5. Have you enclosed Form 147 regarding fingerprints? ,YES ENO RECEIVED EB 1Q20i5 NE BRASK QUO®[rl OtTRO1- �O�y filSs 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 incomplete, inaccurate, or fraudulent. • RECEIVED Signature of Manager Applicant Signature of Spouse FEB 1 0 2015 NEBRASKA LIQUOR ACKNOWLEDGEMENT CONTROL COMMISSION of Nebrask l County of sb p w q ! f - The foregoing instrument was acknowledged before me this Za 219/5"- by 5h-V 6J/ i i is name of person acknow edged Affix Seal N ry is signature Alk's CAROLYN D.STRICKLAND MY COMMISSION EXPIRES 'OVA';, August 5,2016 hima4 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 JAN 2015 Page 6 of 6 iPrint Form j SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT q D NEBRASKA LIQUOR CONTROL COMMISSION C �/ 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 ��1� FAX:(402)47I-2814 Website: www.lcc.ne.eoeoR NEBRASKA L1QU I acknowledge that I am the spouse of a liquor license holder My signature b a_,t 6�srthat I will have not have any interest,directly or indirectly m 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. ___ /fii ° 1 f_ �.�_ ._ . _ar 'ILi 4 4 r5 ignature of spouse as •: • waiver Printed name of spouse asking for waiver r pouse of individual listed Belo State of y ♦_ ) i. ))1252-- County of r C' f1 U �! The foreg•..t instrument was acknowledged before me this by I/ fj r• Mai.- date name of p- ..acknowledged \L ., Affix Seal Slat of Nebr. Notary Public i r: P,fi. GENERALi LISA NOTARY HOFFMAN! _'�_` My Comm.Exp.Sept 19,20f 8 .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 Comm- ion m cane or revoke the liquor license. ,--"eug- CLD i Si . e o individual involved with application Printed name of applying i,indi vidual (Spouse of individual listed above) State of ,11144e-',C5,-X4L County of As- The foregoing instrument was acknowledged before me this if — Z4 ZI/�by 0 it ill/ I `te fl L�da iimi name of person acknowledged , ,► ' ar Aix Seal i Nota y, He 'gn:s e F CAROLYN D.STRICKLAND .iaEk T""'1 MY COMMISSION -" °•.. EXPIRES ��orun; .! , August 5,2018 In compliance with the ABA,this spousal affidavit of non participation is available in other formats fo peFsoirs wiardtsamimia. `'' "+- A ten day advance period is requested in writing to produce the alternate format. FORM 35-4178 Revised 1/2008 Print Form I 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. t L .�.L ka U11/! \e S`..1 cc, u,J t I ai t a r S Si nature of spouse asking for waiver Printed name of spouse asking for waiver (S ouse of individual listed below) State of Q._\,Dc-11960._ \.,)County of t3 The foregoing instrument was acknowledged before me this a-\--\- ‘ by aSSA‘CCA_Ur jaalT15_____ late name f person acknowledged Affix Seal I xe4Eat. No -ste or tiabil Notary Pub nc signature KRISTINAice kg Can S . c 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 v_- The foregoing instrument was acknowledged before me this — _ by�. -- ------ - --- - ---- "•,`k. flank:of pe!sokk 3cknowled;cd Affix Seal �_ Notary Public signature i — 1 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 f .011, N co co n l ' N Ilk ' ICA j , o r t n t.{ 3 flow �yj, cD Nlft4 ill 0 ■ CD N 0 L m b 4 o cv G o %` 73 tv 0 CO CD / c/' fa c c co ° cep' vtift11 Lei { ii Z 2) . , to 0 ro („: 3i 7) (./. AFt ,7) ey zi k e y t e coy m dlif cn `Q it 4 uq t.:6rd --h u 1,6 1. IQ 0_ irql ,,,, cD N Oy). g 5 tilll g 2 : f -. ry # CD t0 F1:1 co IA O o I' Ci -3 ED Co 1 0 c0 k. In r Lrac),c) RECEIVED F B I 0 2.01; NSitQvuUsOsR City of Omaha, Nebraska4,0 N°MAHA, N 1819 Farnam —Suite LC 1 `t Omaha, Nebraska 681 83-01 1 2 i r 711� '^ 0((402) 444-5550 � Buster Brown City Clerk FAX (402) 444-5263 0� '"' 4� FD FEB'R't+ March 17, 2015 U Save Foods, Inc. Application to appoint Steven E. Williams Dba"Bag N Save #785" manager of your present Class "C" Liquor 3003 North 108th Street Liquor License location Omaha,NE 68164 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, •e441'‘‘.24" Buster Brown City Clerk BJB:clj City of Oma1ui Nebraska ;7T OIv1AHA, N 1819 Farnam — Suite LC 1 ri ^r;M sit Omaha, Nebraska 681 83-01 1 2 �� ,�'�„ g�� Buster Brown (402) 444-5550 (,, _ City Clerk FAX (402) 444-5263 0,� " �� 9Th'D FEBO- 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 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, LI Ad ti 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 go/ J No. U Save Foods, Inc., dba "Bag N Save #785", 3003 North 108th Street, requests permission to appoint Steven E. Williams manager of their present Class "C" Liquor License location. 03-31-15;cj r=. RECEIVED Presented to Council: March 31, 2015 - Approved 7-6 Buster Brown City Clerk