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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 Afit --I x OS 03 5' cn ' 0 o = V a3 = 4 A.11_ NXIDT019-10r0.101010_,...TOTFATOV. _A_..0 A 't..‘ ..?.) ,- i v") , 7) 7) ne, —11 0 7) 7) -o CL fl;,' ' al) 1-‘1' (e) --szT ft ' /) tr.) , , 3 V.if. m 7 --A , x n 13 -0 0 v 1 Cl) 3 o= i......,kAi ft 7) t4 (c2j 7' 4t (D CD 74-- W 1\) ''‹ co ttaNk 7) $) ft kr-A cb ,-- 8- toll a) Z : !'- i W 1•—'1,..,. '. :1 0 8 k..s, Q/2 —a CD Zftg , 11 t51 tr. 0 C3) CD t Z La**84 C co —1 = 3 *Q.. z a 7) a) 101 13 ,=.: r.4 CT , ill a kie n7 kr • • .03 tow / i.,-;) k)f fr.) 2 .•.) 7) tr..11 7) 4v-4131irgi „...... ...h. - 1.3 CONTROL COMM'\ISIISIt'br.4 .01110 CO CCI 5' Cn 5 -.4 co 0 ,....) vs., illik szi , -63 : ci 5 co co = Ei i,,, CI Z / 0 )3 ( ig 71 ) -0 0 ril g m §,h ft col [ 7) (Fc.) ) in Ei x _, ..,.. O e_ciftc, bi,H*49 I•11 -/") Om tV F.' es sn. cn _,L.11 .7) V-r ( OT.4.. z- : 7) (Or 73 g CO X 5 ft cb O -‹ -, 0 ,;., co (D Q C) cb 2) ) as o 7), . 1 8c; Z44 Q. h___4414 so -• c") < c / le .r, . 5 't ,P11•44 _/ ' /1A O 44 ---i a - • ..,,'" (a e4 lc) X ni 07 kiel 7) O SI 7) 7) iv h.) , 7) ce- 4..„ ,t- dr. ce- .4: friggfrOfer r- 0:Oil or reNft- cr'' ire- --ir'' _ _ ......, 'E) 10 :u'k BiRNSKA LiQUOR .... ;;- CONTROL COMMISS1 PN 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