RES 2014-0896 - Appoint Eric P McDonald manager of Kum & Go #366 roa a
_y,LyiE 3TATy1ji
' 4 "3 t;
E ..,_
w ''�� • - t s j STATE OF NEBRASKA
NEBRASKA LIQUOR CONTROL COMMISSION
), ` Dave Heineman
hi y; "�a�- Governor d I
Hobert B. Rupe
4ii k,��R / Li Executive Director
r\\ 301 Centennial Mall South, 5th Floor
P.O. Box 95046
l, Lincoln, Nebraska 68509-5046
x; Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
June 9, 2014 web address: http://www.lcc.ne.gov/
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Manager Application Eric McDonald
LICENSE #D-47280, #D-78081, #D-81772
#D-83819,(D-979
Dear Clerk:
Enclosed is a copy of a manager application for Eric McDonald in connection with the Kum & Go
stores #372, #371, #368, #369, and #- . all , .ted in Omaha.
Please present this application fo • s-e - o 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 William F.Austin
Commissioner Chairman Commissioner
An Equal Opportunity Employer
Printed with soy ink on recycled paper
MANAGER APPLICATION Office Use
INSERT -FORM 3c
NEBRASKA LIQUOR CONTROL COMMISS C VED ��c�
301 CENTENNIAL MALL SOUTH Et M /1/&/..�d
PO BOX 95046
LINCOLN,NE 68509-5046 JUN 9 2014 R 21
PHONE:(402)471-2571 C 4.)/i4 , 2p14
FAX:(402)471-2814 NEBRASKA L QUOR 11 74?,) k�4<1
Website:www.lcc.ne.gov
CONTROL COMMISSION A„/ Qv/ R
MUST BE:
1 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$38 per person, made payable to Nebraska State
Patrol. If printed at NSP mail check only.
1 21 years of age or older
t ..S k�k.. 41. ._
Name of Corporation/LLC: Kum & Go LC
?")":,
Liquor License Number: 97931 Class Type D
(if new application leave blank)
Premise Trade Name/DBA: Kum & Go # 366
Premise Street Address:4443 S 84th St
City: Omaha County: Douglas Zip code:68127
Premise Phone Number:402-898-8912
Email address:licenses@kumandgo.Com
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals.
http://www.lcc.n . v/license search/licsearch.cgi
,
SIGNATURE REQUI BY CORPORATE,OfFi ER_/=MA AGiNO'MEMBE
(Faxed signatures are acceptable)
Form 103
Rev 9/2013
Page 2 of 6
•
C �i� F � �..A.��T�z�"�s � v c � �: �" ��n�7�°,��s�� „.,,z xF
Last Name: AA&0 1, _ First Name: i://e., MI:
Home Address (include PO Box if applicable): 9370 0 W2S4 t/,1 AK kyl-i /c'/
City: Orkekt t County: 12c„cptis Zip Code: Y`N
Home Phone Number: Sty-30(.9 ]7/Q Business Phone Number:
Social Security Number:_ Drivers License Number& St Q� k.V
Date Of Birth: Place Of Birth: ZS N : Skit)
2O,4
Email address: [8i4 k�c�,�-� o. Cam °' ,' 0.0
&/aA,
1.--amagaricr, f7f4 'r<
WYES ❑NO
ry
Spouses Last Name: filLOGAtilc-1 First Name: Tigjt MI:
Social Security Number:_ Drivers License Number& State:
Date Of Birth: Place Of Birth: 1MP (��* \k,
9 3"w f 5 3 Y
`4rL src1 air q1 a a" 9
�L� p� .��� _�8 �'�����a�kH��ie6� tl �^� �4 �it� �"' �+st"w� 3 F�^�'� Y"��
5-. ? .;Y:.>.. �&� i,.,..,$^ ,€.,......., >$ r a f-: S•y t . �;{,. et, b' o- t R� �,Y �� + ✓ 5 a ra sSr•e��' .
.,.s a c s?hu,nr ssF �n Y_
CITY & STATE YEAR YEAR CITY & STATE YEAR YEAR
FROM TO FROM TO
0 kIA.A fitstA-1 20,01 .20t,
iLVl tic cf„1 (Ole AIL .Carl Q1 i
t„Kitt •14 7nn6. 2goT RECEIVED
JUN 9 2014
NEBRASKA LIQUOR
CONTROL COMMISSION Re 920113
Page 3 of 6
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO g At: / NUMBER
'�Qc� 2qe''/ � 4 f— a 4 VA�v A 4 1cSCaf`;! Lcz-3` (- 7 0()
o2Q06 �C ( / 4'4 /G /� �d`"` �1/iL f 4�r� 515- f (1 ' 17%
l. 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 occurre Acip-el.,bediar and month of the
conviction or plea. Also list any charges pending at the time of this application. I.. Verily, please list
charges by each individual's name.
❑ YES Er NO MAR 2 2014
If yes,please explain below or attach a separatepage. CONT$RAS(I
A LUQUQ
RCP Conn i `S iON
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mm/yyyy) (City& State) Charge
RECEIVED
JUN 9 2014
NEBRASKA LIQUOR
CONTROL COMMISSION
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
EYES KNO
IF YES, list the name of the premise(s):
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 ONO
Form 103
Rev 9/2013
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: _LA Plccyt) Name on Certificate:
Date
Applicant Name mm/ Name of program(attach copy of course e t ertificate)
( YYYY) 44 � 1)V1-00 "tio.:A4) 04/),(114 Ky.+(,'t No?
*For list of NLCC Certified Training Programs see www.Icc.ne.gov/traininginfo.html
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
/ks,w +
:sL1\1 20(17 le Ak-10 Ky.-t
n,7 l l AL I ..11 (R.
a .zo1� 0M.4110 41 t< -PG
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)
DYES ZNO
RECEIVED
JUN 9 2014
NEBRASKA LIQUOR Form 103
CONTROL COMMISSION page S2of6
RA 4! 011 1ptr: ipiqTd
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.
FilE4c ,
MAR
��. . _.. 2 2p14
Signature of Manager Applicant SiVere
rPOL �4IQt/o�
rr, sIO,v
ACKNOWLEDGEMENT
State of Nebraska
County of b[Xj The foregoing instrument was acknowledged before me this
a?)— W - aOw by tl RE1 LLE ` i-AYAV4
date name of person acknowledged
Affix Seal
ry ublic signature GENERAL NOTARY-State of Nebraska
MIREILLE TAYAWA
My Comm.ExpM.April 12,2017
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 alternateli�mt
.E;VE®
J U N 9 2014
NEBRASKA LIQUOR Form 103
Rev 9/2013
CONTROL COMMISSION Page 6 of
r
�i
SPOYltiA:t,A.Frifl)Avrr OF Otte*IA*
NON'.Y'AR i'IC tPAVION INIStr;W1
te:tikA.iCA LPQUO12 CONTROL COMiM/5YS(3r3
XII CEhrritt,WIA I.MAIL.4Cll.rPh
S)Wte 914i40
r.INCOS.N.IV 034134'=14.1
PlIONII OOP 491-1371
Fey*(4a2)4'H- 6t+t
I owlad a that l am the spouse ot'a liquor hoorso balder, My sigeswitter below eort:inns that 1 will have not have as
Waviest.dlmctty or ltulleecitly in:the operation or profit alibi's lst Wane a(1153-12'3('1J))of the I.lquot Control l Act. I wilt i
tarsi her.Vtrak.suers,eery*pistrona stook shaves,write cheeks.,alga 3nvo1eea or.represent myself ear the owner or in exit
way particlgute hi.the day to day operat#prrs of lhhap-bu tlness litany capes ityy. 1 ondortaiiral my fln wprrtot will not bo
rergtdredf hewarvwr.t am obligated to sign and disakase any irtffrinet7Vn on all applications-ricaded to p oeoss Oils
application. ,,,,, t
- ._. �. —__ 'pre./
t t L ..< .. . ......
titgnatu ()WIC o tics or waiver t3'rin� ,name of sspore a,skin4 fY3r waiver
(Spouse o °.nciividuai hated below)
Crotttty or ?o,t}C- --nw ronsgniaag instrument was eiskrinwiatined before mo I
51._ Ql 4 f _ b Nrnv:xur A �y y
._.......... iruhre par w . __.....�_..
:..: 04ers}Snit •....,......
AMANDA
r l of cry'Public si ure _+ t blb,rtrirla2
My Come fission.
June tit 7ruats .____
1 acknowledge that I am the spouse of the above listed indiv dust I understand that my spouse turd l are responsible fo
compliance with the conditions sit out above. if It is detoaatiased that the abtrwe individual has violated(§53-123(13))tr
Commission may_ts+rtrcerl vr.:evoke the limier license,
Signature of inch vklucai involved with application Printed name of applying individtartl
('Spouse of Intyvltluatl listed above)
State Of,,,...,, , . 'd1 0. .
County of a t i Itts foregoing instrument was eakticswta,dgui'tsc+tusc ssao rt
' --_•.++�' _ .
q
_}L4t-1 !� 4-1 .+ ,YC.J t . , L-. bY .! a!'i�
_ . _rr aarw ofw* ,
'
/US.r 0(61 NOTARYPUBLIC— ?lottery putrilc signature . -------
STATEOF COLORADO• NQTA..f(Y It)201:M000986
ih tva'oplintiet with the AI .»mil A.,qI Li4 I..et AH l�(fo of n e Lim imam n as ewirrt�t!in Wow RV _,S -.-__.». ......_._.___.a..—..._..., -
,a win dry A+Iv,w�Ca FTwkNf a rs�t�d t�s wriri'rtr+o Fh`'"�t�I.e w1r ti+u.re Cesra4wt..
I O.tM-,tt%•
ra.vr..a fa
RECEIVED
JUN 9 2014
NEBRASKA LIQUOR
Eric McDonald CONTROL COMMISSION
District Supervisor
(I(Umt DO
Direct: 515-274-7533
6400 Westown Parkway I West Des Moines, Iowa 50266-9857
kumandgo.comIn 0
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2
4&AHA, NFe
CityofOmaha, Webraskg :k° 1I
1819 Farnam Suite LC 1 AlOritir."1"
Omaha, Nebraska 68183-0112 o ,.,_ :y
Buster Brown (402) 444-5550 A �'
City Clerk FAX (402) 444-5263 o �
'�.�TFD �EBR�t►4`
July 1, 2014
Kum& Go, LC Application to appoint Eric P. McDonald manager
Dba"Kum & Go#366" of your present Package Liquor License location
4443 South 84th Street
Omaha,NE 68127
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 July 15, 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,
46‘lvd A°2°
Buster Brown
City Clerk
BJB:clj
��t11!►NA, NF6
City ofOmaha, Webraska .k 1 I
K
1819 Farnam—Suite LC 1 2 111, ) 1
Omaha, Nebraska 68183-0112 0,4 >
Buster Brown (402) 444-5550 A
City Clerk FAX (402) 444-5263 0 '��D FEBR�v.4A
July 1, 2014
Eric,:P. McDonald Applications to be appointed manager of the
9370 Western Avenue present Package Liquor License locations
Omaha,NE 68114 for Kum& Go, LC (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 July 15, 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,
f4C4'd'A**a
Buster Brown
City Clerk
BJB:clj
KUM & GO LC 4443 SOUTH 84TH STREET 68127
DBA KUM & GO #366
KUM & GO LC 4041 NORTH 168TH STREET 68116
DBA KUM & GO #368
KUM & GO LC 11111 EMMET STREET 68164
DBA KUM & GO #369
KUM & GO LC 13149 FORT STREET 68164
DBA KUM & GO #371
KUM & GO LC 7152 PACIFIC STREET 68106
DBA KUM & GO #372
UM & 0
City Of Omaha
1819 Farnam —Suite LC 1
Omaha NE 68183-00012
Dear City Council Omaha NE,
This letter is to request a change of date for the Hearing on our application to appoint Eric McDonald
manager for our
Kura & Go#368 License 81772 located at 4041 N 168th St Omaha, NE 68116.
Kum &Go#369 License#83819 located at 11111 Emmet Street Omaha NE 68164
Kum & Go#371 License#78081 13149 Fort Street Omaha NE 68164
Kum & Go#372 License#47280 7152 Pacific Omaha NE 68106
Kum & Go#366 License#97931 4443 S 84th Omaha NE 68127
Due to a conflict in schedules we are requesting a move of the hearing date to July 22, 2014.
Please contact me if you need any additional information
Sincerely
Lori Miller
Licensing Specialist
Phone(515) 457-6164
Fax (515)457-0159
lam@kuxnandgo.com
6400 Westown Parkway,West Des Moines, Iowa 50266-9857 1515-226-0128 I FAX 515-226-0995
www.kumandgo.com
is
4
F OMAHA' Ark'
City ofOmaha, Webras&a ;-�\ 4P'd.
vriaa
1819 Farnam—Suite LC 1 m� `� .J -
® 0,�' irk
Omaha, Nebraska 68183-0112 0 1 ro
Buster Brown (402) 444-5550 .o
City Clerk FAX (402) 444-5263 o '7ED FEBR3e+4•
July 8, 2014
Kum& Go, LC Application to appoint Eric P. McDonald manager
Dba"Kum& Go #366" of your present Package Liquor License location
4443 South 84th Street
Omaha,NE 68127
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 July 22, 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.
r Sincerely yours,
44:Ce40,,,dehe
Buster Brown
City Clerk
BJB:clj
City offAlebraskaOmaha
1819 Farnam—Suite LC 1 r��r ' «
®thi s di
Omaha, Nebraska 68183-0112 0� =
Buster Brown (402) 444-5550 .o
City Clerk FAX (402) 444-5263 o4''r �t.4-
Fp FEBR
July 8, 2014
Eric P. McDonald Applications to be appointed manager of the
9370 Western Avenue present Package Liquor License locations
Omaha,NE 68114 for Kum & Go, LC (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 July 22, 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,
,e:134211d1M141
Buster Brown
City Clerk
BJB:clj
KUM & GO LC 4443 SOUTH 84TH STREET 68127
DBA KUM & GO #366
KUM & GO LC 4041 NORTH 168TH STREET 68116
DBA KUM & GO #368
KUM & GO LC 11111 EMMET STREET 68164
DBA KUM & GO #369
KUM & GO LC 13149 FORT STREET 68164
DBA KUM & GO #371
KUM & GO LC 7152 PACIFIC STREET 68106
DBA KUM & GO #372
No. 196
Kum & Go, LC, dba "Kum & Go #366", 4443
South 84th Street, requests permission to
appoint Eric P. McDonald manager of their
present Package Liquor License location.
07-22-14;cj
RECEIVED
Presented to Coun l:
July 22, 2014 - Ipprnved
{
Buster Brown
City Clerk