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RES 2011-0379 - Appoint Mark A Cook manager of Kwik Shop #640 1��\\\\ F SKE STA TF`44 a'- °'^ ` '` �``.. • `2 ��° 'Lt, , ` \l',i, �^ STATE OF NEBRASKA GA F? 4-- .'y s NEBRASKA LIQUOR CONTROL COMMISSION 1a. /�''d��,��`�ui\ '"��ax=/ Governor Heineman _ ;"4 t' :1-, 1n 1 1, r?F t Hobert B. Rupe I\ 4f' Executive Director 1jy 9RCii i^-Wa6^= 301 Centennial Mall South, 5th Floor r I. •r (�w L P.O.Box 95046 '. Lincoln,Nebraska 68509-5046 �i, h�C t '" Phone(402)471-2571 Fax(402)471-2814 TRS USER 800 833-7352(1 1 Y) web address:http://www.lcc.ne.gov/ March 10, 2011 OMAHA CITY CLERK 1819 FARNAM STREET LC-1 OMAHA NE 68183 • RE: Kwik Shop Inc . LICENSE #D - 65384 Dear Clerk: Enclosed is a copy of a manager application for Mark A. Cook in connection with Kwik Shop #640, located at 3606 Leavenworth Street 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, �r•��` CAP)) L 0 e ^ ke Lice ` ision 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 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. / ' jkl go . iig nature f Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. ACKNOWLEDGEMENT State of Nebraska County oX.i f Douglas The foregoing instrument was acknowledged before me this C n0h 6/j 2U / / by M�,-1K 4 oo /C . dme uune of person acknowledged 4- Affix Seal _ 4Y Not Ublic signature :'"i�pF: ROSALIND R.SELLS DEw.,) COMMISSION EXPIRES =t: �•� MYV111 "-•*, ,;- " May 11.2011 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. • Foni 103 Rev Ul011 Page 5 of 5 .._s_ ...r =:.-:-::::: _-�._ :�:T:-:_ _=�::4�a_�_•2L?�� ..�`.=c:'=ic_i—_ra.§P__....e_I�,: ,;,:!, CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Presenl Kansas City, MO 2005 2010 ,Omaha, NE 1998 2005 • , Porm 103 Roy 1/20t 1 Pap 3of5 FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 MANAGER APPLICATION office use INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION RECEIVED 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 ma 9 Z011 ECO\IP PHONE: (402)471-2571 cv FAX: (402)471-2814 �,� ��' Website: ww.lcc.ne.gov CQ TBo(j�C;tlAfl5191Us Qi 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$38 per person,made payable to the Nebraska State-Patrol 5) Must be 21 years of age or older 6) Applicant may be required to take a training course WOW� i» 1i' i4J+:•-r=:�:�-. ._ ., .. ry.... . .... It«st ems:•_'_:_;.��:�srt,�:.r:- a n•,rr.:;r�f.:,._=a_�?:t--=-f�:n��., ..t�.., 1•a •{' S (\j'YI rti _ ' 'I �i t -_:_ -1.:_._„Vi y 1 ig itkS ^L1� ,J'•j�'J}71{I�S:'` jf=�_I�Y i ��lt't • +( fa. i'.4.:'a'st A4, }i J,ii. A r._.:hq� R f,.-...-':-.a'_:_:...yRa AVili,,f� {i JI { {i U W I�i+'.'1i1�1 � r i� !{.I ,it' r ;__ � J c� °=---z:z �a — =�iir.Y�:,r'I'i�.y I f' t 'F: L I J:l,!1a.-� •�_� __rr�J... I ��si.:.c:- -'�:.__�h..- . � � +$l1�:�b,rs:.aJ�--=:_�_=='_• �:�1�lt.�r?a�+ r.::� Name of Corporation/LLC: Kwik Shop Inc ..,,}_ l'.1!" . T1NTaf --.. iµ4UStM '!f i•'tiX•r,=?c ;,tee �1 ..f i•'....._�.• ;;--z- tiv�":•-1Y- li'.�.�.. ,rl� ynY '1,fh•��yh I�;'.^P.• {1 M( ,r . . �s'�4. '�i� �'�1{=-r �J=1_ �'�� f��.; f,�� 1. ,it�r,..� � ;� 1�:'il. •ifk,311. 7., - 1 -- N iii !lt V! ii r„rl Jrxrl ,S � , _ t � �; :r ��,� .. .. Its�i:i F. � a _:r�+� �, u �lUtidu:c.��,.•�,-.-�_._,�_:_ �,. G,d_' � 'ti�, k•ii Premise License Number: D-65384 (if new application leave blank) Premise Trade Name/DBA: Kwik Shop#640 Premise Street Address: 3606 Leavenworth Street City: Omaha State: Nebraska Zip Code: 68105 Premise Phone Number: 402-341-1308 The individual whose name is listed as a corporate officer or managing member as reported on insert form 3a or 3b must sign their name below Brian Fisher, Vice President, Kwik Shop Inc. CORPORATE OFFICER/MANAGING MEMBER SIGNATURE (Faxed signatures are acceptable) rmm 103 . Itev 112011 Pwgc 2 of 5 CITY&STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2010 Presenl Kansas City, MO 2005 2010 ,Omaha, NE 1998 2005 • , Porm 103 Roy 1/20t 1 Pap 3of5 FROM TO FROM TO Omaha, Nebraska 2010 Present _ Kansas City, MO �2005 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 , , Mana Oli5:tlf4laaat iilli i �:. .7 .. ► ,� �. 1 : . Ti ......_..._ g.. ....._._ _. _..._,:11; ,•?: , .lid ,:::.,.::.::_::::::............__...... .. •-.:-,elic —_ _, ?ir:'.:: .,.._'=}i...; -a..5 L51._..._pJ .J_til•r!....r,ly - - _ ______ .. his:_ ___ �r 'fi�l'� tip' •-• r•.=_ _ _. �T .__ i3r, ': .:` � k-'-"1'�''eci, c_ -= t- ••:�a'- ZwL'� ,f�' i �..}ssi:.�..� -�i�'la?.e o. +}ia'•sisex-�iSr•:•r4; r_?s-Y:�. •.2:�-a_._�f-;._.-----=�:?�a'r'�-�---.s_. -'%t;.a.. e.• District Advisor Gender: ®MALE ❑FEMALE • Last Name: Cook First Name: Mark MI: 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 ..�:-:•_:�._-;--.1,-�._;=='---.--••+,*_;t':�'--�w=��pis�.=+- ....�,i .ir:,•�,i,lit •Fh'N'f�. K x:' r"tlr.::uas;�'+'°'�'M;.�ir:t,�•�;:,,t'SI:';;,iylh " ':i;A�'.."AP __,... .. � � t: __ .jam.:..._:.:.. _t;Tk4 :r, . i- ; i . '` - 'k : uz s i' ��,f,11' ':!,i; g.I lk _:+:�• 3s_:>.� �;�Fd �,. a1r�''��'�'•i:' ''�L''' I �'i •I�'`ii � } ,'!� is ,�`. i i�, ', r�,`� tit',;�: y� .}� ��r�;;-:1T—;: 44-,_ _#: _ikAlit'alt.. Sr..t. iC � it Id� �s F�l�`' �;i ' I l' 1� '' i'si ? A l! .:}."' irWi':: DYES ®No rOttriailfilitriiiiatiVaggaralf,a;::,:��art�:ap:;. : .:}•,:_.._._ M,+ , Y .}. sI. t i ., '.t:r;:•E�'*,tica�.::�: _ ;.�+��+.�;9ngr..; Pr ire, � II R .} , I� ry� �' �' �, , .�7�' ��:,�:_...:ri Sat �, ,,-.5-:}a`•'' ', }: ;ii } i,, ; cif' t,:�1'�tr }.•r,::}_las_ _:s _:-- ,:__0- ;,�1„r!,. .Ilf i I I 4 it T:.;T::- :: �t=:;.:--.._......... ,.. ,�j , h,•, }•a ,� ,ill '�� ; . 1•i3 '=' _s T?_=�`__r� ss�i c:$�istcx�I d�� i Alr'cL.• 1' +�tr�! l�J ' �n dCa �> � � iili� ra,.' f-�::-.. Spouses Last Name: N.A. First Name: MI: Social Security Number: Drivers License Number&State: Date Of Birth: Place Of Birth: c�Y .-...__-__`=_.._.. _. _g �4,... �vym ,n, : }'1L •r n�n�}�annr v,n•r aYlr�n q}-,•ua„� _ _ - .; _ _ . ... ... .'ram =�'::>;'i a - *� — =�h -�as �avii �} i I ;:a 4; t Fr• 'r-"1!y�.. �- rt !_i''. lq kt��rf <}1,1~�u��+ .s�:!�'_�._.._ ...-- — � --- .._.._..._.___ ___- -- LI r,:±�' .' Eihf 1., is a _r = __—--_-__ -_= i:._;_;;;,:_f''' _! ?.� i CITY &STATE 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)2011 Page 3 of 5 -- 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 �:�r_ieri..-r.+.9 +crr-Beyer. :rtramer:�:-..-..r...;.:._...:.. _ _ __ _ _ ___ __ __ _ _ -"R'x '''fir?i!!F_�b-.�.:.�i:.�n•.-.• �. r�r:. :_••�•,=..i� y:van!it:�i:a .t...r_-:❖:. .. 'V , .s.. _ �� ,.,..�.�.,.....:, .,, ,�:_. "i..:..,.-_.,:•:• -=:.� �-�-- �Q�1.1'�-Y'��...,.r. .�..r:;s„� �',�.�:�. �;'i�:as��'` w-�r�1 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 AG - iT O S :.R :V 7W-W-�z:' "I ,..TJ TIOPKBE O, _k'' �: - � ..._.. ._.....v^^.-x_ . ... �_� .:.... : ::'.r::� �'_i� _ram.}.1�_ TPI sa 1.11 t=_eleae .s:- ._ `S'_:� - � __�.J ,� ._� 7 ._`• . ..... ....._.._...:..�...._.....: ��.:--�:mLrts:m«r•::.-xr.=a-u-s�:a-mrc-2�.._. _�::. .r:r. !n.�`!�rns..x.:.:.1 .f•_..� :E,s1•'<P:r i--s�'��'.:-r::�2 I. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. I-Ias any9ne 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. D YES [I NO If yes, please explain below or attach a separate page. Name of Applicant Date of 'Where Description of Charge Disposition Conviction Convicted (min/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 IF 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 NO 4. 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) [AYES ❑NO form 103 Itev 12011 Pogo 4 of 5 . ... ... .'ram =�'::>;'i a - *� — =�h -�as �avii �} i I ;:a 4; t Fr• 'r-"1!y�.. �- rt !_i''. lq kt��rf <}1,1~�u��+ .s�:!�'_�._.._ ...-- — � --- .._.._..._.___ ___- -- LI r,:±�' .' Eihf 1., is a _r = __—--_-__ -_= i:._;_;;;,:_f''' _! ?.� i CITY &STATE 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)2011 Page 3 of 5 -- 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 �:,1' ryr,�1,,e}"r:ii^";h.nt:�V _ _ 1..}:n _ ��la ,.;ii;;. _ a,�,.e ..fe. .#;.. .'r.'1.4'-:—}'�?r? i - `s �i`F.!i?1`��i:�i'.:,?`Y.,�-�} t t, .n.,,L ""' _ ::�:�-,-::p:.:_•ap_.r•.7�g �t'•i?Ip. ,l',v�`Mtl':'a'Y:��l r Mtt; ���,' •t: .i i,i'''� .r.,r r�' ). '�,' %,`.,;,�,r?f�`-�2 �.f'!;`_'�,.�'!F!��t:_�':'_t::�t;�•;�;.�ao:'+: hate. F.,1...gk H_......y... r i ,�:;l 1.� 1 ".; piS 111„;•tin .iE ;i „ iiit i.._•4.44 •___..t,.._...t...:..:......_„,-: t!.,.. lit ate ....-._ ; I�;,_,d. '- ,,:.. lYl'�c. }- Y;:' .._ �T �r' •,: ���;i:. .h�.. ��=. itxsGzSl�:uc'twa'rr:•► 1':'`-!�+fi:' .'.�� �F�41d7�!�V�i i'' �.'R � ' Kiss?- yi i';:i@�i •L ;" i7 '`T' � 4 it r i �.� titYl ( rl y:��( Ria• 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 tights 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. / Xi g441 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. ACKNOWLEDGEMENT • State of Nebraska County of Douglas The foregoing instrument was acknowledged before me this �a/Ch C"/� Z�� by ,.)6(-: 4, /C dale , mn�ne of person acknowledged Affix Seal Notary ublic signature `''' '.'.1' I Y(.' 55'� 'c,.t,.. _3 1ti .,. 7 i t? ...t . ., - 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. • Pond 103 Rev 12011 Page 5 of 5 ,Omaha, NE 1998 2005 • Perm 103 Rev)2011 Page 3 of 5 -- 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 City [Ale o Omaha bras&a :,DeAntiil 1819 Farnam —Suite LC 1 2 ; 9'. Omaha, Nebraska 68183-0112 0 , Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 0'�-sTgD FEBILv��`� March 22, 2011 Kwik Shop, Inc. Application to appoint Mark A. Cook Dba"Kwik Shop#640" manager of your present Package 3606 Leavenworth Street Liquor License location Omaha,NE 68106 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, Z; 4.1‘,2 Buster Brown City Clerk BJB:clj 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 tights 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. / Xi g441 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. ACKNOWLEDGEMENT • State of Nebraska County of Douglas The foregoing instrument was acknowledged before me this �a/Ch C"/� Z�� by ,.)6(-: 4, /C dale , mn�ne of person acknowledged Affix Seal Notary ublic signature `''' '.'.1' I Y(.' 55'� 'c,.t,.. _3 1ti .,. 7 i t? ...t . ., - 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. • Pond 103 Rev 12011 Page 5 of 5 ,Omaha, NE 1998 2005 • Perm 103 Rev)2011 Page 3 of 5 -- 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 O iv F 44 City of Omaha, Webras&a4.1 I l- Dirk4v-%en 1819 Farnam Suite LC 1 �wr, f � Omaha, Nebraska 68183-0112 o Buster Brown (402) 444-5550 .o ,.- eV" City Clerk FAX (402) 444-5263 O�4TED FEBR��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 ding 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 tights 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. / Xi g441 Signature of Manager Applicant Signature of Spouse Mark A. Cook, Distirct Advisor, Kwik Shop Inc. ACKNOWLEDGEMENT • State of Nebraska County of Douglas The foregoing instrument was acknowledged before me this �a/Ch C"/� Z�� by ,.)6(-: 4, /C dale , mn�ne of person acknowledged Affix Seal Notary ublic signature `''' '.'.1' I Y(.' 55'� 'c,.t,.. _3 1ti .,. 7 i t? ...t . ., - 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. • Pond 103 Rev 12011 Page 5 of 5 ,Omaha, NE 1998 2005 • Perm 103 Rev)2011 Page 3 of 5 -- 2010 ,Omaha, NE 1998 2005 _ Perm 103 Rev 12011 Page 3of 5 4 n o1 po °. � Q. ` r O 0 " . > v) P *'‘ \ .__.S-2. O P cA N ' n � CD EA o FD- to4 D1 O 0 '� W CD a O O, o CA 'd .,• vV co0 La cv a o aw