RES 2014-0616 - Appoint Sharon K Schwartzkopf manager of Cheap Smokes STATE OF NEBRASKA
ct l {; NEBRASKA LIQUOR CONTROL COMMISSION
Dave Heineman lHobert B.Rope
� Governor Executive Director
kat OtM1 301 Centennial Mall South,5th Floor
P.O.Box 95046
r+ } _ Lincoln,Nebraska 68509-5046
Phone(402)471 2571
Fax(402)471.2814 or(402)471-2374
TRS USER 800 833-7352(1 TY)
2014 April 18, web address:http://www.lcc.ne.gov/
OMAHA CITY CLERK
1819 FARNAM STREET LC-1
OMAHA NE 68183
RE: Manager Application Sharon Schwartzkopf
LICENSE #D-50330
Dear Clerk:
Enclosed is a copy of a manager application for Sharon Schwartzkopt in connection with Cheap
Smokes, located in Omaha.
Please present this application for manager to your City/Village Councilor County Commissioners and
send us the results of their action.
Sincerely,
�4k� cns2:�1
Jacqueline Rodriguez
Licensing Division
NEBRASKA LIQUOR CONTROL COMMISSION
402-471-2571
end.
Janice M.Wiebusch Robert Batt William F.Austin
Commissioner Chairman Commissioner
An Equal Opporhanity Employer
Printed with soy irk on recyc'ed paper
MANAGER APPLICATION office use
INSERT-FORM 3c EC IVE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH MAR 2 4 2014
PO BOX 95046
LINCOLN,NE 68509-5046 NEBRASKA LIQUOR
PHONE:(402)471-2571 CONTROL COMMISSION
FAX:(402)471-2814
Website:kyvvy,„.,,Ice pe o.o.%
"" •
MUST BE:
1 Citizen of the United States. Include copy of US birth certificate, naturalization paper or
current US passport
1' Nebraska resident. Include copy of voter registration in the State of Nebraska
1( 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
Name of Corporation/LLC: 7he F //jp9 31j410 r-2 rc
* iiuuuiiuiujiuiiiurnuumumpuuuipuiiiuiuuuiiii
Liquor License Number: 5'03 a Class Type
new application leave blank)
Premise Trade Name/DBA: 6/leap Sitwoh..-ec
Premise Street Address: 3202- L . '67-
City: ernel County:
IS Zip Code: 6,8/07
Premise Phone Number: 1/*0 -73,1 Vol
Email address: (9104)6 rot r,:e4., yono.) coal
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with o mission. Click on this link to see authorized individuals.
http://www.leene, rch.cai
Aiiipre~ Afe "11 *
•.7 r:17,741Y./e6"41;:iyrt 778 DR4A , .14
(Faxed signatures are acceptable)
1111 11 Form 103
Rev 9/201..3
1 I Page 2 ot 6
1
1400009267
Manager's information must be completed below PLEASE PRINT CLEARLY
Last Name: Sci-A 03 a kc) First Name: S‘-)(),v-nr) MI:
Home Address(include PO Box if applicable): I 11 J 6q�`' `Jt"
City: County: Li Zip Code: t 0 R
Home Phone Number: 4 q 1- 74p5ii Business Phone Number: 4 09.. -7 31 " 1 `b 1
kJ ka
Social Security Number:, Drivers License Number& State:
Date Of Birth: Place Of Birth: btAn(.'t jl UTS 5 , `Ifl
Email address: do 1:4. a + p-C t'"1
Are you married?If yes, compete c' ➢3information(Even if 4-1PPuqgd,aflid "ed)
►Z! YES [�NO � �
litatiOrk
S u 's in nn t anieV ."
Spouses Last Name: S e h oJa rtz kop First Name: n n MI: J(
Social Security Number: Drivers License Number& State
Date Of Birth: Place Of Birth: Y " rt. i Co
APPLICANT&SPOUSE IVI.UST LIST li SIDENCE(S)HR`THE PAST TEN(10)YEARS
APPLICANT - SE
CITY & STATE YEAR YEAR CITY & STATE YEAR YEAR
FROM TO FROM TO
7010 2013
ri� il+ s, R 19 9 Ire _. . .. .._
,�,Q •rz:f 7,015 c irfA
Form 103
Rev 912013
Page 3 of 6
ANAGER'S LAST TWO EMPLOYERS
YEAR TELEPHONE
NAME OF EMPLOYER NAME OF SUPERVISOR
FROM TO NUMBER
,b j 0. r> 0` 112 - 352
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.
❑ YES 074 NO C NED
�
If yes,please explain below or attach a separate page.
Date of Where Description A Lv Linaii)R
Name of Applicant Conviction Convicted ot" a _r
(mm/yyyy) (City& State) Clt c
I
•
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
OYES lO
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?
,`YES 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.
Shav ' t.S7riZ
*NLCC Training Certificate Issued: 'Ma1�� Name on Certificate: r /t
Applicant Name Date Name of program(attach copy of course completion certificate)
*For list ofNLCC Certified Training Programs see v°ww.(c€�..n ruin c fig ht i
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment;
S c (iguc,rvc qk { U t4i1 Ska OC ITV OreriPi' Z Nwc t--31 -40,0 L 0.0,1 oc /*
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 O &IACS 40 £..k.- l(;t,t ta bc.i P
Form 103
Rev 9/2013
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 §53-13 1.01)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 in .f 11sccurate, or
fraudulent.
r
Signature of Manager Applrant Signature oil Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of *mac,; : " ( 1 The foregoing instrument was acknowledged before me this
E
, name of person acknowledged
/ ff r
Af7ixSeal y. ......�
Notary Public signature
GENERA! NOTARY-State of Nebraska
e. TYLER J PRCHAL
My Comm.Exp.Sept.24,2017
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 alternate format.
Form 103
Rev 9/2013
Page 6 of 6
. -
SPOUSAL AFFIDAVIT OF Office Use
NON PARTICIPATION INSERT RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 MAR 2 4 2014
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814 NEBRASKA LIQUOR
, ,
Website: \\\,\\ 16:lit:4(iV CONrROI, 47. .7)"-MiS .ION
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Signatu of spouse asking or 'aiver Printed name of spouse asking for wafer
(Spouse of individual listed below)
i. i
State of '--
,,,,
County of (Jo L.,,,i14 . The foregoing instrument was acknowledged before me this
--- I i by i,7,,E,,':,4,- / ,/1,t
,ydate ..., name of person acknowledged
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9 " Public signature 4'. -' Affix Seal % GIME VOTARY-Site of littooska
.,.„
X TYLER J PRCHAL
N
Comm Exp.Sept.24,2017
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P141Cfrlita*10 ' t, Aie,abovelisted*Ilvidual
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Signature of individual involvecy‘ith application Printed name of applying individual
(Spouse of individual listed above)
State of ,•.\fe.,,i;', '`-'..
County of ),;,,ae. ',,, The foregoing instrument was acknowledged before me this
3_,,,,,,e)., .... /r -----ie
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by /Mr' rn,. Z
name of person acknowledged
NI/‘ Affix Seal
---.E..-.--. 41,1 Comm.Exp.,Sept 24,2017
. ;will GRERAL NOTylERAfri-Stata pRe ofemitobrasAL ka
axt 1;' tic signature
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
OMAHA, NFe
City ofOmaha, Ne bras a :_ .
mtifei;„zrel'=,
1819 Farnam—Suite LC 1 `~ J -y«a
2
Omaha, Nebraska 68183-0112 0v ;� ;
Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263 O�41'Fp FE1!9.
April 30, 2014
The Filling Station, Inc. Application to appoint Sharon K. Schwartzkopf
Dba"Cheap Smokes" manager of your present Package Liquor
3202 "L" Street License location
Omaha,NE 68107
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 May 13, 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,
Aele"
Buster Brown
City Clerk
BJB:clj
OM�HA' Art,
Cityof Omaha, Nebraska .0 .
.17
1r'' ir
r�.l ern
1819 Farnam—Suite LC 1 z d
Omaha, Nebraska 681 83-01 1 2 �® ro
Buster Brown (402) 444-5550 �A �
City Clerk FAX (402) 444-5263 O443 FEBRt►44
April 30, 2014
Sharon K. Schwartzkopf Application to be appointed manager of the
11713 South 209th Street present Package Liquor License location
Gretna,NE 68028 for The Filling Station, Inc., dba"Cheap
Smokes", 3202 "L" Street
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 May 13, 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,
441die/r1"
Buster Brown
City Clerk
BJB:clj
No.
The Filling Station, Inc., dba "Cheap Smokes",
3202 "L" Street, requests permission to appoint
Sharon K. Schwartzkopf manager of their
present Package Liquor License location.
05-13-14;cj
I
RECEIVED
Presented to Council:,
May 13, 2014 - Approved 7-0
Buster Brown
City Clerk