RES 2015-0379 - Appoint Steven E Williams manager of No Frills Supermarket #800 04�auna A rF,t,�4
k C` t` F 1 V E Ul STATE OF NEBRASKA
4(16.+►: 1 Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION
4 ° Governor Hobert B. Rupe
ait `it ., +� 2015 MAR -9 AM 9: 140 Executive Director
Rom' je 301 Centennial Mall South, 5th Floor
P.O.Box 95046
CITY CLERK Lincoln, Nebraska 68509-5046
Phone(402)471-2571
M A H A. N E B B 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
LICENSE #C-99125, #C-99126, #C-99127, C-9912 #C-99130
Dear Clerk:
Enclosed is a copy of a manager9ation for Steven E. Williams, in connection with the No Frills
Supermarkets #795, #797, #798,( and #802, all located in Omaha.
Please present this application for manager to your CityNillage Council or County Commissioners and
send us the results of their action.
Sincerely,
qacy4.12,6%/2.,_;---R0-4.141,,,d7
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 3e
NEBRASKA LIQUOR CONTROL COMMISSION RECE1\15)
301 CENTENNIAL MALL SOUTH 2O15
PO BOX 95046E
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 L QU
FAX:(402)471-2814 uSRNS ow'tMSS °
Website:www.lcc.ne.eav 0 - R°�.
MUST BE:
✓ 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/LLC information
Name of Corporation/LLC: vecS �nc-
Premise information
Liquor License Number: 0 0.9. Class Type c (if new application leave blank)
Premise Trade Name/DBA: t\\n VYZ
Premise Street Address: 30o'L(o S.
City: 0 County: Conn-S Zip CodeW I O
Premise Phone Number: `'10 2.-39 1 - a-'ri
Email address: N ,�� ` (� Sc-r -- is 5\.LOm
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals.
http://www.lcc.ne.g6v/license search/licsearch.cgi
SIGNAT REQUIRED BY CORPORATE OFFIC ER / MANAGING MBER
(Faxed signatures are acceptable)
Form 103
REV JAN 2015
1500003692 Page 2 of 6
Manager's information must be completed below PLEASE PRINT CLEARLY
Last Name: Wi t—t.-i 0(vx 5 First Name: ct—$.7-ki t,3 MI:
Home Address (include PO Box if applicable): IL\1? coL,mk 1.0-1¢° /JJG
City: anA t4 County: , S Zip Code: 6e5(.3
0
Home Phone Number: 462- _ '7? Business Phone Number: 40 z- 1. -Ca5a
Social Security Number:_ _ _ _ Drivers License Number& State: . tV11stc4
Date Of Birth: — Place Of Birth: ��oLix ►i5.,,4
•
Email address: *'?- l e- -i-j•11 to M SQ,(17-Y-A,J IASA,C o rv►
Are you married? If yes, complete spouse's information(Even if a spousal affidavit has been submitted)
BYES ❑NO
Spouse's information I
Spouses Last Name: OtwiA j First Name: S�tr c.0 MI: R
Social Security Number: _ - - I Drivers License Number&State:1 . ,u _ ivlj
Date Of Birth: Place Of Birth: �l�-�ilc�cs= ��gR s-i4A
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
A /1 �
unn A"41- PiC-G a5t4A 1 icle e.;rtr6-
mom_
FEBFV\117-:1-'
CaLl O
- S age
CONTROL
Form 103
REV JAN 2015
Page 3 of 6
MANAGER'S LAST TWO EMPLOYERS
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM nnTO NUMBER
' '! t ei' RAQsAJn?ASrt fVttzZ ,c-etAl 40z-537-(/;o0
ictgo 20 &Vges 5 e. o2 1.4,14, tiDL-ei35-L,4•42..
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 one party, please list
charges by each individual's name.
N] 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
� A/4 �"`^� Zvi !LSQ .C4A 124
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
JC YES ONO
J!`111 �,Ck3. . L i,'Cc ant E sq.,4
IF YES, list the name of the premise(s):
GtiONIAR, digs S. 17� Li ,7c.�.o ,J 6, iS-vZ
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?
EYES ANO
i `
r a
} 1 U a
Form 103
JAN2015
�°A i 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: 'Clyvorotalb Name on Certificate: STEc.J
Applicant Name Date Name of program(attach copy of course completion certificate)
( YYYY)
()CA.) (,itti-L %S /9oi3 (Z►�S
CFCJ i,3 W 1f.L:,ar1S ? 2 $�U •1..Llr 4-1Op C r,o r8 Ceti-tA3G►t�
*For list of NLCC Certified Training Programs see www.lcc.ne.gov/traininginfo.html
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
//i$ Z- 2. /yqo-aoot 4; -c 5pr. e('e,$ o / m
f5 r D.2ecL dCX�I -o�[� Sg4`TA i 5-4 �C.�r`+�A�i - (.o(/0Wf��
STek.)L(..at-t.-.n 1$`At ac e[-c-Cterr,,— Sc,d i i ' fi OfWAt- ,a ,JE
5. Have you enclosed Form 147 regarding fingerprints? :,
YES (lNO
CONTROL ieONiIM f.T lON
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.
Signature of Manager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State of Nebrask bra—
County of Dt,L9 The foregoing instrument was acknowledged before me this
ji-atcR-12t/ ZO/5 by 3kf& /iii lI/k" t.
d e i name of person acknow edged
_ _i t�'�V�ez L�:��i,& _ Affix Seal
. is signature
,.04..; CAROLYN D.STRICKLAND
3,7 * MY COMMISSION EXPIRES
'', y r,• August 5,2016
J
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.
FEB 1 0 2015
Form 103
r } REV JAN 2015
±''$� ZA,- .SK_ 1J11M1 t,J Page6of6
Print Form I
SPOUSAL AFFIDAVIT OF Office Use" "
NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION i" 5
301 CENTENNIAL MALL SOUTH
PO BOX5'5046 NEBRASKA LIQUOR
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 CONTROL COMMISSION
FAX:(402)471-2814
Website: www.lcc.ne.;!ov
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 m 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 tins 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,
ignature of spouse as ' for waiver rinted name of spouse asking for waiver
pause of individual listed w)
State of N hYgs Ka 71311.—
County of :C oU { The foregoing instrument was acknowledged before me this
` by 14t7ti1
name
aat of person acknowledged
K Affix Seal
NOTARY-State of Nebraska
Notary Public i re ISA L HOFFMAN
e-- ' • My Co .Exp.Sept 19,2015
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:. can - or revoke the liquor license.
A _ c--,,s.
n
Si e o Individual involved with application Printed name of applying individual
(Spouse of individual listed above)
State of R_ -
County of --Lta-4/ The foregoing instrument was acknowledged before me this
a/EGG it
Z�i 2/1�� byJiWI ///_. 6
date name of person acknowledged
,��� )� 410 Affix Seal
Not y blic.'gn: ate :'t'i P% CAROLYN D.STRICKLAND
=.i"== 4 MY COMMISSION EXPIRES
11 MOTS: -
�a;;�'---Atlgtlst-5 t6
In compliance with the ADA,this spousal affidavit of non participation is available in other formats .
A ten day advance period is requested in writing to produce the alternate format.
FORM 35-4175
Revised 1/2008
IPrint Form j
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-I25(l3))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.
L..\e-s,s t c ( I I i.Q J
Si nature of spouse asking for waiver Printed name of spouse asking for waiver
(S ouse of individual listed below)
State of Q.\9c J C A-.
County of \)(:).t\� The foregoing instrument was acknowledged before me this
(9 try —(.Jt, , Yn
,, name at person acknowledged
midi
\i*Airr-
V Affix Seal
�, l .NOTARY-Strreellie nda
ary Public signature KAISTINAPOSTLEWrAIT
My COMM Bo Decent VON 4
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_-
name of,...soy,acknowledged
Affix Seal
li
Notary Public signature
f
J
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
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CiILY of Omaha NebraskaoMAHA ��
1819 Farnam — Suite LC 1 7 wort!juju
Omaha, Nebraska 681 83-01 1 2 n „-_�'� 1
14-
Buster Brown (402) 444-5550 7�. -
City Clerk FAX (402) 444-5263 0e
944'D FEBOI'4
March 17, 2015
U Save Foods, Inc. Application to appoint Steven E. Williams
Dba"No Frills Supermarket#800" manager of your present Class "C" Liquor
3026 South 24th Street Liquor License location
Omaha, NE 68108
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,
Buster Brown
City Clerk
BJB:clj
City of Omaluz, Nebraska OM1AHA �,�
filko
1819 Farnam — Suite LC 1 �i i.� ��_�� slit 7,
Omaha, Nebraska 681 83-01 1 2 VA rkireit
Buster Brown 0 WI 1
(402) 444-5550 �� ;, , ,y
City Clerk FAX (402) 444-5263 �•P " �`4�
44'D FEBR�.
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,
e‘401/di.a:
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
Z'd/(s
No. , 37q
U Save Foods, Inc., dba "No Frills Supermarket
#800", 3026 South 24th 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 D
Buster Brown
City Clerk