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RES 2014-1158 - Appoint Brock A Thornton manager of Quicktrip #579 8(:-.,' ''• -- a'4 STATE OF NEBRASKA 4yt a M40 >,, ,,- h Dave Heineman NEBRASKA LIQUOR CONTROL COMMISSION �M1�i`�)!:1 ', ''= Governor a1516 j�, Hobert B. Rupe v"., , In►�s , 8J9 Executive Director •:- ilb 301 Centennial Mall South,5th Floor N. P.O.Box 95046 4 0) AVG 201 N Lincoln, Nebraska 68509-5046 cp ,ven 4 Phone(402)471-2571 August 8, 2014 `— R cm AER a, Fax(402) TRS USER14 or(402)471-2374 800 833 7352(TTY) S�� 4►1 web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK �� n 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Manager Application Brock Thornton LICENSE D-3322)#D-61680, #D-70743, #D-40529 Dear Clerk: Enclosed is a copy of a manager application for Brock Thornton in connection with th QuikTrip #579, QuikTrip #580, QuikTrip #585 and QuikTrip #588, 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, , ar.ILLG-k'F ,)u_. 0.nt-'2 .1 ,r'1 2 Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION 402-471-2571 encl. Janice M.Wiebusch Robert Batt William F.Austin Commissioner Chairman Commissioner An Equal Opportunity Employer Printed with soy ink on recycled paper MANAGER APPLICATIONk` Office Use z V INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION ,3< 301 CENTENNIAL MALL SOUTH PO LINCOLN,BOX 95046 E a S L 1 HON : NE 68509-5046 oN oL ciM i Si PHONE:(402)471-2571 FAX:(402)471-2814 Website:www.lcc.ne.gov 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. Two cards per person,fees of$38 per person, made payable to Nebraska State Patrol. If printed at NSP mail check only. ✓ 21 years of age or older Corporation/LLC information Name of Corporation/LLC: QuikTrip Corporation Premise information Liquor License Number: D-033224 Class Type (if new application leave blank) Premise Trade Name/DBA:QuikTrip # 579 Premise Street Address: 1 704 S 72nd St City:Omaha County: Douglas Zip Code:68124-1702 Premise Phone Number:402-391 -2904 Email address: 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.gov/license search/licsearch.cgi SIGNA R REQUI D BY RPORATE OFFICER /MANAGING MEMBER (Faxed signatures are acceptable) Form 103 fihi'ill 'fillIllIiihIIllh!I!llllfllhIllhIllTh 1400018277 Managers information mustbe completed below PLEASE PRINT CLEARLY • First Name:Brock MI:A Last Name:Thornton Home Address(include PO Box if applicable):818 S 188th Terrace City: Elkhorn Count,_Douglas Zip Code:68O22 Home Phone Number:515-577-1006 Business Phone Number:515-252-2437 Social Security Number: Drivers License Number& State:, NE Date Of Birth. Place Of Birth: Iowa City, IA Email address:bthornto@quiktrip.com re you man red`?If yes,comple a spouse„anformattow(Even f a spousa[affidavit lzasLeen submitted) • YES ❑NO ;Spouse's information 3 Spouses Last Name:Thornton First Name:Megan MI:S Social Security Number: Drivers License Number& State: NE Date Of Birth: Place Of Birth:Geo na, NE APPLICANT &SPOUSENIU ,LIST RESIDENCE(&)FORLTHE PASTTEN(10)YEARS • APPLIC '3tYEAR _� SPOUSE CITY& STATE FROM YTO CITY& STATE FROM EAR YEAR YEAR Ankeny, IA 10/02 12/13 Ankeny, IA 10/02 12/13 Form 103 Rev 9/2013 Page 3 of 6 MANAGER'S LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 4/18/1994 present QuikTrip Tom Gehrke 515-276-5010 1993 1994 Bonanza 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 anv 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 *.Month of the conviction or plea. Also list any charges pending at the time of this application. If 't'i e 'arty, pl ease list charges by each individual's name. ❑ YES C NOt 4s , If yes,please explain below or attach a separate page. NIPBRASKA L..I U OR CONTROL COMMISSION Date of Where Description Name of Applicant Conviction Convicted of Disposition (mm/yyyy) (City& State) Charge 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? RYES ENO IF YES, list the name of the premise(s): f 4 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? YES ENO Form 103 Rev 9/2013 Page 4 of 6 Stores inNebraska: stm�� 57933224 '1704S72ndSt Omaha 58061680 6045L5t Omaha 58570743 472U Hamilton St Omaha 58643534 1311 Fort Crook Rd N Bellevue 50761678 4404N72ndSt Omaha 58840529 4212S84thSt Omaha - 58992612 5305N103rdSt Omaha 59436645 71555add|eCreekRd Omaha 5963I477 50055108th3t Omaha 59783481 8727 Maple St Omaha 59949789 13007CiSt Omaha z� �� c~ nm �� - ~~ �� 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued: n/a Name on Certificate: Applicant Name Date Name of program(attach copy of course completion certificate) (mm/yyyy) AU{a )4 Og', *For list of NLCC Certified Training Programs see www.lcc.ne.aov/traininginfo.html Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: 5. Have you enclosed the required fingerprint cards and PROPER FEES with this application? (Check or money order made payable to the Nebraska State Patrol for$38.00 per person) ❑YES •■NO Form 103 Rev 9/2013 Page 5 of 6 PERSONAL OATH AND CONSENT OF INVESTIGATION 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. CEIVED r iC_CN Signature of Manager Applicant SignatuR,.a�, f i ACKNOWLEDGEMENT Cam_ State of Nebraska County of 1(r. The foregoing instrument was acknowledged before me this 1f t date name of person acknowledged ( f� Wr.,. ki 61 c ,(.0`'fl'I Affix Sea] p1At.4� MARY AN 1 Notary Public signature $ �* cOMMtSS1ont8RiS . � MY COM', ,oN t !� rows 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 9/2013 Page 6 of 6 Print Form SPOUSAL AFFIDAVIT OF Office Use r. NON PARTICIPATION INSERT �Y ., NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH A E> 8 PO BOX 95046E.i 'r LINCOLN,NE 68509-5046 PHONE 02)47l471-2 71 FAX NEBRASKA LIQUOR Website: vvww,ice.ne,goy CONTROL comM E I N 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. ( Megan S Thornton Signature of sp use asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) State of County of fr7C-'1 The foregoing instrument was • acknowledged before me this fC..3 f i4 by � � t person ac,7 1 date v r�1 Affix Seal lA�� -� fut � 6 li l r � A► ,' cco#ANi{SSICt�1 NO I $ Notary Public signature . ;n MI Oti1M ESSIOPJ S i 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. "4, 131 Brock A Thornton 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 5 / by 11/1(91-kie571 dat name of person acknowledged � -4_ Affix Seal MARY ANN THORSHEIM Notary Public signature f 44 COMMISSION NO.748187 * MY ISSION IRES ,owe �'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 0 AHA. NF6 City ofOmaha, &klebras&a I. $4C311 T 1819 Farnam- 2 44"o adrZfrirttila a Suite LC 1 nvir (r if o Omaha, Nebraska 68183-0112 0,4- `;� #; :�.,_ co Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 o�4TED FE1 9. August 26, 2014 QuikTrip Corporation Application to appoint Brock A. Thornton Dba"QuikTrip #579" manager of your present Package Liquor 1704 South 72nd Street License location Omaha,NE 68124 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 September 9, 2014 . 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 ��®MA�IA, �1►F8�7 City ofOmafia, fAlebraskg �11 t i ) 4,1 1819 Famam-Suite LC 1 r Omaha, Nebraska 68183-0112 0 � ', Buster Brown (402) 444-5550 ti, City Clerk FAX (402) 444-5263 047'FD FEaRA August 26, 2014 Brock A. Thornton Applications to be appointed manager of 818 South 188th Terrace the present (9)Nine Package Liquor Elkhorn,NE 68022 License locations for QuikTrip Corporation (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 September 9, 2014 . 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 QUIKTRIP CORPORATION 1704 SO 72ND ST DBA QUICKTRIP #579 QUIKTRIP CORPORATION 6045 "L" STREET DBA QUICKTRIP #580 QUIKTRIP CORPORATION 4720 HAMILTON STREET DBA QUIKTRIP #585 QUIKTRIP CORPORATION 4404 NORTH 72ND STREET DBA QUICKTRIP #587 QUIKTRIP CORPORATION 4212 SOUTH 84TH STREET DBA QUIKTRIP #588 QUIKTRIP CORPORATION 5305 NORTH 103RD STREET DBA QUIKTRIP #589 QUIKTRIP CORPORATION 715 SO SADDLE CREEK RD DBA QUICKTRIP #594 QUIKTRIP CORP 5005 SO 108TH ST DBA QUICKTRIP #596 QUIKTRIP CORP 8727 MAPLE STREET DBA QUICKTRIP #597 C/A- Es No. QuikTrip Corporation, dba "QuikTrip #579", 1704 South 72°d Street, requests permission to appoint Brock A. Thornton manager of their present Package Liquor License location. 09-09-14;cj -719 t RECEIVED Presented to Council: September 9, 2014 -Approved 7- Buster Brown City Clerk