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RES 2011-0377 - Appoint Mark A Cook manager of Kwik Shop #622 KE sTAra,a v z\ E 1 ` V ��l STATE OF NEBRASKA d / NEBRASKA LIQUOR CONTROL COMMISSION °�'W Y:y Dave Heineman _!i `4+ '"�! Governor + ;j,� {{ 8• ?a Hobert B. Rupe �y l�Fj i �' �' Executive Director ?e.15 301 Centennial Mall South,5th Floor P.O. Box 95046 CITY C L t r I., Lincoln,Nebraska 68509-5046 A H.A, 1‘,I i_ r7 /1. ; ; Phone(402)471-2571 Fax(402)471-2814 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ March 10, 2011 OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 r RE: Kwik Shop Inc LICENSE #D - 67219 • Dear Clerk: Enclosed is a copy of a manager application for Mark A. Cook in connection with Kwik Shop #622, located at 9545 Q Street in Omaha. - Please present this application for manager to your CityNillage Council or County Commissioners and send us the results of their action. Sincerely, • 11010LIV Lynn Licen '-• Divi in encl. cc: file Janice M.Wiebusch Bob Logsdon Robert Batt Commissioner Chairman Commissoner An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper uster Brown City Clerk BJB:clj instrument w s acknowledged before The foregoing instrument was acknowledged before Z u) 1 byme this me this 7�„� (� by • (1-4 -14/ Public signature. Notary Public signature • Affix Seal• Affix Seal Here are mi.' Aim M • • In compliance with the ADA,this manager insert form 3c is available in other formats for persons with disabilities. A ten day advance period is required in writing to produce the alternate format. Revised 9/2008 • Form 3c Page 4 Notary Public signature SHARON BOWEN *Scalia.Exp.,Nn,18,2015 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 .. .. tat_.... . _ YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO , 1995 PA.ear Va2-enti:no'a fOUJ McA4^Lneo 402 434-9350 nEu:, ,te �. ^^'� 41ws .yAy. may,., -fit•..` t icy y+ _ ;i;;5.{� ,v�,S,Fr. y 'p .•Y,ea�;,r",;. . Zr, _.a :$ .;1..n; ' .1..',.:WII y-l:Y;y.;r'i :; 1 t c'e;: :1., —24 .1+1Ig:pla:"ls r- '. , Form 3c Page 2 • 'ar � ~1 a3�fk4,5,, wJ'� p • �'44f, h Y: i t ,rr- ,�+ l.� x :fie s:Z4. , .. ,..^F•• ,r `.i . .. : d:'•:%. {*: Y.-..1.. �3 , t.. �, 'xC /I' Form 3c , 1100004026 MANAGER APPLICATION ORia use �(�(r'D�(�n f12(� INSERT-FORM 3e L� l� U�J(c lD • NEBRASKA LIQUOR CONTROL COMMISSION MAR 0 9 2011 301 CENTENNIAL MALL SOUTH PO BOX 95046 nlEBRASKALIQUOk I IaI PTLINCOLN,NE 68509-5046 C0�1TR01 Cnn.o isSIQN PHONE: (402)471-2571 c FAX: (402)471-2814 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 their fingerprints(2 cards per person) and fees of$38 per person,made payable to the Nebraska State Patrol 5) Must be 21 years of age or older 6) Applicant may be required to take a training course 4V. wax d r"YS+ai'•f;F' tzkr:'ra:m-. - .:,�_ n i tart;�Vims:'_-:_��y-��:,r: i, }"I n �•.s;�r.,ti_r-,=_�?:�_-=:k�_�., •N � }}�1��(t` � � y�' t.. hr�_��:_..:�J,�r i,i'�',!i•��I� tY.� ��;��ri7 =_" _.-:.4.:L I -Elora k x; k i 1 --`_ `1 ,,_'-F .;! .. L +ti`l � wisif=ma.Err • k:;- F.i,,0 l; ,.., 11 j� , I?4== _, �. •A.i. 7 ti. It $ r 1 `!'.VI t _1_ a._M..: �_ !' t�:.,--::::�:._., �� - r 'ce '4�. fk+l�llY1��1 �ilw9itN'°'��ff�'F�t ?1jlj�:,r'=3 . :-_ M Y 51.t.. 2 iM12 4-r t:.2-__;1_. _'_- k d r} 2LI!,!• Name of Corporation/LLC: Kwik Shop Inc • ,,r_ e►�� . ,TrRME—OnkiftyRl1" - ;,..,._�,{•._..._�.. . - =-=--� ram'"%` 1Y'i+;r-�''�* r�! I;'•.,'"f '1!�p°r��..f[1`s!'ia!•'polj ' r,p ! =A7 = 1 -� f 5 ;f .v 3! f �, tisrrIII1! f l- = r !s 4-�--_'-;=ice'- �r!1 - � i33 �� ._ _--- -fM=_?��;�.;?.t y + r' �`1�'ui E► lk�l ' . -�'—.J , � , e a_ 4 •ri. bil.x M� iifi l—`sroiz:e ka . . !'Nta>! J.a •r�a:U�e:F�_...`__.:�_ �� .,'vI t3{Rt�l�aufs.:.s;,;�.,�,.,...,�:._!�°_ 6,�-:. �,llt.��u�# ,.�...�I'e+: � .fG. 1:,1� Premise License Number: D-67219 (if new application leave blank) Premise Trade Name/DBA: Kwik Shop#622 Premise Street Address: 9545 Q Street City: Omaha State: Nebraska Zip Code: 68127 Premise Phone Number: 402-331-1248 The individual whose name is listed as a corporate officer or managing member as repotted on insert form 3a or 3b must sign their name below \tp ' Brian Fisher, Vice President, Kwik Shop Inc. CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) tom%lea $cv viol I • Page 2 of 5 � ~1 a3�fk4,5,, wJ'� p • �'44f, h Y: i t ,rr- ,�+ l.� x :fie s:Z4. , .. ,..^F•• ,r `.i . .. : d:'•:%. {*: Y.-..1.. �3 , t.. �, 'xC /I' Form 3c , 1100004026 • 1 . mana ells tufounat .uln .>t', .. a _..lo�v= ?> ==A.E R1N.P:G , �' ....._..._ g....... ........ .._..._ _ - .::_:: „_fie.;:. �� , ,. g •:;p _ _-......__la_...iii,:i_.:._._.:...._...-s_-. ........................................k----_ . • [�Er':v-::,=:::::_::_::=_ --- �. .— 5. ... .n��_�. l�S:,rI.':,;n� s-��-_-=^�_Ys=__...__:..�-- _.� .�_ter.. � == 3�i�isx'-.f �fu'Y.:: =�'tsr:'t:ar._:-_.Y:�.' 5 1 - �-•_-__ - •� .-. a....er...c:•,i�iii,fti District Advisor Gender: ®MALE ❑FEMALE ' Last Name: Cook First Name: Mark • MT: A Home Address (include PO Box if applicable): 7333 N 77th Street City: Omaha County: Douglas Zip Code: 68122 Home Phone Number: 402-557-6212 Business Phone Number: 402-391-1808 Social Security Number: Drivers License Number&State: NE - Date Of Birth: ------- - Place Of Birth: Omaha, NE -�:--:�.._.:::::a '-..... •. ,f��.r�w=_��s;�.r'�11 *" , 'h:.'d. ..fgti.. .A,N'f"." 1.�.:"': R %a I:'�gKi,Fjini�''ttpr)i.o.. 1 i;'' � !��_ 1 f.. ;1 i r { i•(' t:• �{�yh�') h , j .; :': '�E•3}i:,_=.. , �-_.'i•`_,,„ , ffil:�.'y' �`y`yt f f'i,7. rt .1 •�F ;l��. �1.V',`,i,if, '�[',' .+,i,ii:' 1 lir1,4�ri•:n•.,,JKXS}j yi'y1 ,V . �1 ut Y:11M1 i 'W' ki it L�G ' .in , ` .1 !' '� . -_... S�..�f.R?L173•�-t: ::T�l �,i�:,.:�•..,. r..ti. •>i �� 41 S�� 1L• L+;IL '��$!?? �. '' .�_ D YES ®NO -- - ..ir�g=�:�:}�,=c Q__ -r�cf=' = a�v�::ic:�_.,, a'r�.r� }ih:P,' 'P`+. 1' �t• , •{ y°�+r��:;_=:cLi S se... '� i sge,4.VAIT: ;1 „{r, r,S} `�`` ' �• t, .I •{ :::, r.... .Siu.nX.r...r..: '-�' t-,. .e,'$•l�ti:nisl 1 ht!"�I 4 � „., �g ' .' .I 1 ' jp5',�j�� 1 0 1, ;�_"�- .._. TAiiV= C�i' ai:• :::fir_ ➢iri}`.i. '. g:-S`':11+Ip't1 {M�l11JgJ{ (1i'J1�11•,1Q{ real{�i rF�fi� .p{I A IA"`�h�J7L� > r¢...fig_gl ..�_. �'r�7,.�'•'�'•f.-:es•r:'•-=•.�....o ,._r1:... ,.-•:;•, ,..•,�'� ;ah!.��.'�3SL'I�.'"��fIYI�IV'; �tt:it;l� L'� � �) � � � a- '� r.__ _'.e__,,=ii�.''� —��+_e��:.._�°.r.c. -tz�r3•`.{ , { Wf: i .i ti 1 t� �+.�.-'ri6,�'�{,=a:.=c°,�:� Spouses Last Name: N.A. First Name: MI: Social Security Number: Drivers License Number&State: Date Of Birth: Place Of Birth: • FLIfGrANT&I fiF-. Q E:myStI': 7 _ + , . -- - - - jF.riti :i = =::s=_;_—_r.=.. -l� ,j,-� -- y-`.; 'lam;1 ytt1 v, u. S, ; >:ai Ja466. ^r __ r �.I'- .,t TA N�Iitigrr :'j _tfi:i1l:S-- __ :___L__ _ _ - _ _._;i2 :-1„1-2:yt8%.1::y:.i�,•-iii:'.� L 1l E_''bhf=ks..l.._ '.. . _a�i,n:� �::=r.'�r,':yL_ := . y.._s=__ - -- ;.. .__. _—: h CITY&STATE I YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 • i•,:p:_�-:i.ni,�efi''+s}i.��imr �p:rerrmlr'�::: .:. : _ _ _ __ _ ___ __ __ _ _y"�➢•1 y4 r•�+�„�r�•.Y;r 1F_:b-:�`•�4•F...�••,—:",� r..p�...�fr,�. :_:.v:'.:.r.�...:*Ci...,n;_qa.;m;r.'F.:,1..-:: ,iia .. '.l,. .r'�"' .•.1r :'11Y`., k�lr:Tilt••kli�Y!_�rt..�—L�:_.y.._,..—_ - � r: ��-?�' '��':: S�_'Hl��!;�:79.=.51!n7S�. :.r7,r� �a�+w� •''3�.L�:ri`di:..i...�r.We:'J • YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER ,2006 2009 CVS Pharmacy Rich Hayes` 913-383-3652 1980 2006 Osco Drug Rich Hayes ,913-383-3650 AGER'ANI):a.O S : RVIENV ;_l T O_NS:3 I o: — .- , r: � .,Y ......... .;. .. '�.�-�::•. ----_ _. .._ --_ —_ =-1__ �.-- '1'---- .....:... _:a::'^�=_s_''�;;ram _ - - P1 sa rl t:_cleat —__ : ' : ::�. -, -r f ., rn - .r.:-==�-_._. .«... ..yam.—:�i-��vr_. c � � S' `,r-v.•z?I�T'—_��:5•`.•� t �{s�i.�,'•• '�� 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. I'Ias 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 [j NO if yes, please explain below or attach a separate page. Name of Applicant Date of Where Description of Charge Disposition Conviction Convicted (mm/yyyy) (city&state) NA 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES ONO IT YES, list the name of the premise. 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 4. Have you enclosed the required fingerprint cards and PROPER TEES with this application? (Check or money order made payable to the Nebraska State Patrol for$38.00 per person) EYES ONO ram 103 ltev 12011 Pogo 4 0(5 rth: Place Of Birth: • FLIfGrANT&I fiF-. Q E:myStI': 7 _ + , . -- - - - jF.riti :i = =::s=_;_—_r.=.. -l� ,j,-� -- y-`.; 'lam;1 ytt1 v, u. S, ; >:ai Ja466. ^r __ r �.I'- .,t TA N�Iitigrr :'j _tfi:i1l:S-- __ :___L__ _ _ - _ _._;i2 :-1„1-2:yt8%.1::y:.i�,•-iii:'.� L 1l E_''bhf=ks..l.._ '.. . _a�i,n:� �::=r.'�r,':yL_ := . y.._s=__ - -- ;.. .__. _—: h CITY&STATE I YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 } .tom. . ::::.,:: f P';^•...'_ ,R{. ..: 1 !, ' �,;F.!(.� , {, )f .'.rjj,S'+knn 41,pirt 1 r��st:�'i'w,I% �r�t';�� Y: s� a f�'� ,i"�� 3:�� ''""� t f'� .i �!. ! �, i..::!A�%:G'11H?�'J�.4}:{!!•:Li'tilr�2i'1!. W,IriM:!�N, hlb�l� .<� Y: KK'lil..�l7"�:Y.{i Yl�:��N_'1.LR4..11.,�_::irc.f:r"=__a�s.iY•r:-:.y:�.`_ 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. 161j/ ("(171 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. • ACKNOWLEDGEMENT State of Nebraska County of Douglas The foregoin instrument was acknowledged before me this vc h q, 2_0I / by �� %o cook •dale nnune of person acknowledged Affix Seal 7._ ROS*.J1.J R.SELO Notary sig store MY CC','ASS:C:1 E„rmaS • 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 12011 Page 5 ors ogo 4 0(5 rth: Place Of Birth: • FLIfGrANT&I fiF-. Q E:myStI': 7 _ + , . -- - - - jF.riti :i = =::s=_;_—_r.=.. -l� ,j,-� -- y-`.; 'lam;1 ytt1 v, u. S, ; >:ai Ja466. ^r __ r �.I'- .,t TA N�Iitigrr :'j _tfi:i1l:S-- __ :___L__ _ _ - _ _._;i2 :-1„1-2:yt8%.1::y:.i�,•-iii:'.� L 1l E_''bhf=ks..l.._ '.. . _a�i,n:� �::=r.'�r,':yL_ := . y.._s=__ - -- ;.. .__. _—: h CITY&STATE I YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 City ofOmaha, [Are bras ' . lCIPOrtirei �� 1819 Farnam—Suite LC 1 if `- Omaha, Nebraska 68183-0112 0� ;, � Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 O'Q41.FU FE1 ?. A March 22, 2011 Kwik Shop, Inc. Application to appoint Mark A. Cook Dba"Kwik Shop#622" manager of your present Package 9545 "Q" Street Liquor License location 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 April 5, 2011 . 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 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, .4( 6,; Buster Brown City Clerk BJB:clj 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. 161j/ ("(171 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. • ACKNOWLEDGEMENT State of Nebraska County of Douglas The foregoin instrument was acknowledged before me this vc h q, 2_0I / by �� %o cook •dale nnune of person acknowledged Affix Seal 7._ ROS*.J1.J R.SELO Notary sig store MY CC','ASS:C:1 E„rmaS • 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 12011 Page 5 ors ogo 4 0(5 rth: Place Of Birth: • FLIfGrANT&I fiF-. Q E:myStI': 7 _ + , . -- - - - jF.riti :i = =::s=_;_—_r.=.. -l� ,j,-� -- y-`.; 'lam;1 ytt1 v, u. S, ; >:ai Ja466. ^r __ r �.I'- .,t TA N�Iitigrr :'j _tfi:i1l:S-- __ :___L__ _ _ - _ _._;i2 :-1„1-2:yt8%.1::y:.i�,•-iii:'.� L 1l E_''bhf=ks..l.._ '.. . _a�i,n:� �::=r.'�r,':yL_ := . y.._s=__ - -- ;.. .__. _—: h CITY&STATE I YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 AHA, City ofOmaha, [Ale bras /c 1819 Farnam— Suite LC 1 z i� -� r, Omaha, Nebraska 68183-0112 0 ;. Buster Brown (402) 444-5550 #A City Clerk FAX (402) 444-5263 o��T�� FBR�t•�4 March 22, 2011 Mark A. Cook Application to be appointed manager of the present 7333 North 77th Street Package Liquor License locations for Kwik Shop, Omaha, NE 68122 Inc. (see attached list of locations) 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 April 5, 2011 . 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 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 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. 161j/ ("(171 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. • ACKNOWLEDGEMENT State of Nebraska County of Douglas The foregoin instrument was acknowledged before me this vc h q, 2_0I / by �� %o cook •dale nnune of person acknowledged Affix Seal 7._ ROS*.J1.J R.SELO Notary sig store MY CC','ASS:C:1 E„rmaS • 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 12011 Page 5 ors ogo 4 0(5 rth: Place Of Birth: • FLIfGrANT&I fiF-. Q E:myStI': 7 _ + , . -- - - - jF.riti :i = =::s=_;_—_r.=.. -l� ,j,-� -- y-`.; 'lam;1 ytt1 v, u. S, ; >:ai Ja466. ^r __ r �.I'- .,t TA N�Iitigrr :'j _tfi:i1l:S-- __ :___L__ _ _ - _ _._;i2 :-1„1-2:yt8%.1::y:.i�,•-iii:'.� L 1l E_''bhf=ks..l.._ '.. . _a�i,n:� �::=r.'�r,':yL_ := . y.._s=__ - -- ;.. .__. _—: h CITY&STATE I YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 . P v, o Cri - o CD o Np. � ci 1 on CD 5 G n s l W cr1,g"fi• dl:0 (...) O 0. N CD 5,0 N LA L N tom, s O .. ,_ . N