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RES 2013-1047 - Appoint Eric McDonald manager of Kum & Go #347 o 'q L_ -t°'- STATE OF NEBRASKA , r y Dave Heineman 13 " '1 f �- LIQUOR CONTROL COMMISSION �,� � NEBRASKA .. ° Governor Hobert B.Rupe YY _ Executive Director i "; 301 Centennial Mall South,5th Floor P.O.Box 95046 Lincoln,Nebraska 68509-5046 ' Phone(402)471-2571 July 17, 2013 Fax(402)471-2814 or(402)471-2374 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 RE: Kum & Go #347 LICENSE #D-042736 Dear Clerk: Enclosed is a copy of a manager application for Eric McDonald in connection with the Kum & Go #347 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, ad-121.z/Y2/7 Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION 402-471-2572 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 AECEW NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 �e� PHONE: (402)471-2571 NEB�� hhh�l� +�© FAX: (402)471-2814 GC3���c�P� Website:www.lcc.ne.gov Corporate manager,including their spouse,are required to adhere to the following requirements 1) Must be a citizen of the United States 2) Must be a Nebraska resident(Chapter 2—006)and must provide proof of voter registration in the State of Nebraska � 3) Must provide a copy of one of the following: state issued US birth certificate, naturalization ,..) paper or US passport 4) Must submit fingerprints (unless a non-participating spouse) (2 cards per person) and fees of$38 per person, made payable to Nebraska State Patrol 5) Must be 21 years of age or older 6) May be required to take a training course Name of Corporation/LLC: Premise License Number: 0 - 4-1 ,a / (if new application leave blank) Premise Trade Name/DBA: l�C1 U # 0 y Premise Street Address:3 3s p. /V 10' -,-�- City:© . State:N/" Zip Code: c gy e Premise Phone Number: The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b or listed with th Commission. Click on this link to see authorized individuals. httn://www.lcc.ne.2ov/licens arch/lice rch.cai CO RATE F CE A AGING MEMBER SIGNATURE (Faxed signatures are acceptable) Form 103 11 r Rev 11/2012 Page 2 of 5 1300016507 �, ti a 9 J 6 v,p P x a t m ' • a '„F, ;'' . ,a.! �� .� fEt� cl aleaE� �r ,ii�x d aJ ,l+Etalt� �4e+ s P, ` , ,��4 �• z, , r-7f31, ,Ca, . ,,,, , 5�.� .,. �L 1 t4 r1 df,, r ..,, + Lei „,, r t, s �. a.,, .,.: Gender: /*�MALE OFEMALE `��' " l�'4�ru kt NEL-i able tr��� ce Last Name: n� First Name: r ht-r 1 4ni nfIAallOKS! 1 Home Address (include PO Box if applicable): ! 70 Lu.<e/9,/�z'-1 4- /S y �n City: Q,„.jK County: —_-Js Zip Code: 687/ Home Phone Number: $3'J7t 77/0 Business Phone Number: 5!f-3Q4,•7770 Social Security Number: _. - __ ._ Drivers License Number& State: WE , Date Of Birth:_ Place Of Birth: 6/'a Ati<<41 1EY YES ONO Spouses Last Name: ,41c1„a/J First Name: T,s,'(a MI: 4 Social Security Number: . Drivers License Number&State: , :..1 Date Of Birth:_ Place Of Birth: Alta i (if) , TA • •' .. r CITY& STATE YEAR YEAR CITY& STATE YEAR YEAR /� FROM TO FROM TO 92-70 �r In ,�11k #W mif is 20/3 2- �01t 7n�tk' 'leei, dCG4.(y 5yf� O lintlint ,AK (A114 �! krEa,,,,.lac, TA ,feY. ), 2140(e 2009 .31n11 SW -riM&t>ll+,‘, 6-.4 Dcf.66, Plod' ga l,44ta!-f1 . Cam,1'/k1. 4 ,.-s.1. 125r.1a- 4nku,y TA 501:1-23 air)II ICI) i' U sR e,*2t7 �qau 20a(4, 1.31 ,A4t.! Apt c,.dt jt,(Y cc-6;,.r EiIa,u•,,,,-)3 Si ds2) , CO V6431 .479 20 if Form 103 Rev 11/2012 Page 3 of 5 YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER A ,2o ) rct 20,9 Ric l.O l r F W {a ca-{ 102•J Ti• ?p4D &In I{-4 `, 7r15- 1-319S 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-participation. Has anyone who is a party to this application, or their spouse,EVER been convicted of or plead guilty to any charge. Charge means any charge alleging a felony,misdemeanor,violation of a federal or state law;a violation of a local law, ordinance or resolution. List the nature of the charge,where the charge occurred and th ( . n e conviction or plea. Also list any charges pending at the time of this application. If mor .. a list 9��t�. charges by each individual's name. YES NO I yes,please explain be ow or attach a separate page. l it .a /11i : Name of Applicant Date of Where Description o$! "' 1a�1� ..� s Conviction Convicted �pN-rl�r 1 f°f 1AAIfl�l +�� (mm/yyyy) (city&state) 2. Have you or your spouse ever been approved)LE made application for a liquor license in Nebraska or any other state? ®YES U10 IF YES,list the name of the premise. 14La, 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? IlliVES 10 4. Have you enclosed the required fingerprint cards and PROPER FEES with this application? Check or mone order made payable to the Nebraska State Patrol for$38.00 per person) S10 5. List any alcohol related training and/or experience (when and where). '`Cp G,/.ie --.0/0-21// pt,.., -20%-20a2 I.44 4w,1 Abca,t -`i tAi Form 103 Rev 11/2012 Page 4 of 5 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. C // 1 Signature of Manager Applicant S ature of pou• se ACKNOWLEDGEMENT State of Nebraska County of tDO(`-NLj The foregoing instrument was acknowledged before me this Di 09 J ra0r3 by glAie? M lwet LLL —1s a— d• 1.o . . ... • .. •- d 405 ail Affix Seat MIREIU.E PA TAYAWA is signature • My Comm.Exp.A XN 12.21111 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 11/2012 Page 5 of 5 pgGe ,skit, 4 COlOgrIl SPOUSAL AFFIDAVIT OF PECEN „'t o.li.c 1 _ NON PARTICIPATION INSERT it NKaKA#Kw 1.494KW t c1N'ctu,a.c4.MMtsst01.4 JUL 1 f ZO13 .#t It T , l�dl;t 303 CENTtNAa1AL.MAt.4$t?4rIH t tQ I C t nox 41046 LiNcot 74,Np4asus-saw. RABKA L PRONE lw�f�7c•xs�e NEB 51ON r`+�E�I�sri'.�tnri t,ttrct�'C)F� FAX c1On•*e.2ti,4 CONTROL COMM COW/Melt r4"l tifilie + ITi+ Wen Ito AMOICALOSMIN 1. -. nrt ' I ., .it "111 :011 +'• w ,-t et a. 1117' i. , L ,I c a '," 7- i i -'pr, , k d q ,a ti _�L rr le,0 ) . ,` "a • - . • ,1 f l 7 1 s >1 # Wv..:!,,,- __:-.?,...,-,.;kr:0.-7:",..:?..,31....,_ § - _ . a t,yway .tIk _ F 4 ° ` i , al be'��yy,.��� '1t�E 1. It (a s ai � 1� 4ri' yly 1 0 ,fie i tsd � ''';''''1,'' app�,tlt2�fk7 �' ;- 1. . _ ,, t`y .,� 'P AV. $ s ,`'f .p'� ni'i, a Signature o use asking r waiver Printed iwnc of spouse asking for waiver (Spouse of i •tviduaI listed below) Suite of V ____ County eat--beilial..A5 The foregoing Instrument was acknowledged before me this Q-I 4 Ocl J mJ by It- _. ram., bite no me of peteart rNciwwIpr8 chill 4, *swoon ii1 h h An*sow 6r 11A1 110101111144 SOT�Y W* j! �1 t*r aoew.w m.oon+a.soil 1 NI it a 'tl� 1�31t�'l�. the 1 aclaiqvdedge th4 I am the wow o e.fl ltidt ei to 11 t t���1igY..4 ;.,;, f , .- °i..,.�'r�IYMif' �• b e fbrr.. compliance' the oondi 'ou*f ' t hire dete>nriI chl " ,, ' zr, •.i :_ 'isollledUf3 415(13))the Commission may cancel or invoke the Ueitief cen -4• .. :a,_ .4; �, ,,,;, A .t .. Signature of individual involved with application Printed name of applying individual (Spouse of individual listed above) State of Aii?f'tt? \° County of ' )1 X The fimegoing Instrument was acknowledged before me this C'1_ 'ice \ 1:7 by .► t 1t....l r3 tP4. ..,. ...., N ottiry,.PEits'1Ie si at r{+ F 014AHA, NF6 CityofOmaha, Nebras a �� 1 I' 4'1 W.-./111111<":4161 1819 Farnam Suite LC 1 �® 'Cr Omaha, Nebraska 68183-0112 0,4 �( Buster Brown (402) 444-5550 'PA ti City Clerk FAX (402) 444-5263 0 41F0 FEaRNt44- July 30, 2013 Kum& Go, LC Application to appoint Eric P. McDonald Dba"Kum & Go #347" manager of your present Package Liquor 3352 North 108th Street License location Omaha,NE 68164 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 August 13, 2013 . 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 OMAHA, NF ebras a �zt o Omaha, lI = ' 1819 Farnam Suite LC 1 ®l,� kt dt Omaha, Nebraska 68183-0112 0.4 Buster Brown (402) 444-5550 114A City Clerk FAX (402).444-5263 o � �`�rFp FEBR4 July 30, 2013 Eric P. McDonald Application to be appointed manager of the 9370 Western Avenue, Apt 104 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 August 13, 2013 . 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, /1).,9) L,„7. Buster Brown City Clerk BJB:clj PACKAGE LIQUOR LICENSES —MANAGER'S APPLICATIONS Kum& Go #347, 3352 North 108th Street Kum& Go #348, 12011 Blondo Street Kum & Go #351, 720 North 108th Street Kum & Go #352, 1010 South 154th Street Kum & Go #363, 1819 North 72' Street Kum & Go #364, 8990 Boyd Street Kum & Go #377, 8242 Maple Street Kum & Go #378, 14353 "Q" Street f7//y No. Kum & Go, LC, dba "Kum & Go #347", 3352 North 108th Street, requests permission to appoint Eric P. McDonald manager of their present Package Liquor License location. 08-13-13;cj RECEIVED Presented to Council: August 13, 2013 - Approved ; - Buster Brown City Clerk