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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 `,, Please consider the environment before printing this e-mail. CONFIDENTIALITY NOTICE:This email message,including any attachments,is for the sole use of the intended recipient(s)and may contain confidential and privileg unauthorized review,use,disclosure or distribution is prohibited.If you are not the intended recipient,please contact the sender by reply email and destroy all copies c message.Please note that while we scan all e-mails for viruses,we cannot guarantee that any e-mail is virus-free. 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