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RES 2011-1259 - Appoint Louis E Stinebaugh manager of Bag N Save ,SHE STD„„„ � RECEIVE STATE OF NEBRASKA ors %%a,,-,�;��` v a°, ,!' Dave Heineman NEBRASKA LIQUOR CONTROL COMMISSION ==' _ Hobert B. Rupe rad t _,�,.:,- Governor i , qr y • ! ( �� ^`^t ICI /O Executive Director \9RCH ‘� � 301 Centennial Mall South, 5th Floor _ P.O.Box 95046 CITY C i-F `1 i Lincoln,Nebraska 68509-5046 O M A H A, N F t A S i<, t, Phone(402)471-2571 September 30, 2011 Fax(402)471-2814 or(402)471-2374 TRS USER 800 833-7352(TTY) web address: http://www.lcc.ne.gov/ City Clerk 1819 Farnam Street LC-1 Omaha NE 68183 RE: Bag N Save, Inc DBA Bag N Save Manager Changes - License#'s(C-64667J C-64666, D-57629, C-91109, C-91111, D-28377, C-64665, C- 64673, D-91110 • Dear Clerk: • Enclosed are copies of manager applications for Louis Stinebaugh in connection with Bag N Save, located at the following locations: *3003 N 108th Street, Omaha NE 68164 14444 West Center Road, Omaha NE 68144 770 N 114th Street, Omaha NE 68154 • 15370 Weir Street, Omaha NE 68137 2650 N 90th Street, Omaha NE 68134 5017 Grover Street, Omaha NE 68106 7646 Dodge Street, Omaha NE 68114 5110 S 108th Street, Omaha NE 68137 1826 Vinton Street, Omaha NE 68102 Please present these applications for manager to your City/Village Council or County Commissioners and send us the results of their action. Sincerely, • /76__ejti j(e /71 Michelle Porter Licensing Division Enclosure Janice M.Wiebusch Robert Batt William F.Austin Commissioner Chairman Commissioner cc: file An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper MANAGER APPLICATION Office Use INSERT -FORM 3c ite` itSCD pf NEBRASKA LIQUOR CONTROL COMMISSION SEP $ 2011 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRRd Y�LIQUOR LINCOLN,NE 68509-5046 GOM11TROl,f,'Q ,IISS101`' PHONE: (402) 471-2571 C 0 FAX: (402)471-2814 Website: www.lcc.ne.gov '- T 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 Corporation/LLC information - ? Name of Corporation/LLC: Bag N Save, Inc. Premise information -- "--" - --- _ Premise License Number: 64667 (if new application leave blank) Premise Trade Name/DBA: Bag N Save Pre -i-se ddress: 3003 N 108th Street ty: Omaha State:NE Zip Code:68164 Pre "se Phone tuber: (402)493-5833 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 lzc CO E OFFICER/MAG MBER SIGNATURE (Faxed signatures are acceptable) Form 103 Rev 12011 Page 2 of 5 le An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper kleatiltra Manager's information must be completed below PLEASE PRINT CLEARLY 144 ._ _ - - _ - ______ — _ SEP 2 8 2011 - . Gender: 0 MALE ❑ FEMALE NE8RAMLIoUOR Stinebaugh Louis GONTROI.cOMM,ISSIO, Last Name: First Name: MI: Home Address (include PO Box if applicable): 16570 Sage Street Omaha Douglas las 68136 City: County: Zip Code: Home Phone Number: (262) 227-7559 Business Phone Number: (402) 885-7899 Social Security Number: Drivers License Number& State: NE Date Of Birth: Place Of Birth: Greenville, Texas 'Are you married? If yes,complete spouse's information (Even if a spousal affidavit has been submitted) _—I ❑� YES ❑ NO ISpouse's information _.-_ Spouses Last Name: Stinebaugh First Name: RobinMI: D Social Security Number: - - -- . --- Drivers License Number& State: - ,vE Date Of Birth: Place Of Birth: Shawnee, Oklahoma APPLICANT & SPOUSE MUST LIST RESIDENCES)FOR THE PAST TEN(10) YEARS— 1 APPLICANT _ _ SPOUSE__ _____ CITY & STATE YEAR YEAR CITY & STATE YEAR YEAR FROM TO FROM TO Omaha, Nebraska 2008 Present Omaha, Nebraska 2008 Present Edmond, Oklahoma 2007 2008 Edmond, Oklahoma 2007 2008 Morgan Hill, California 2006 2007 Morgan Hill, California 2006 2007 �6''' rnwn) (l)i Se-ons 1 vt 200 I .ce to .5,0'l0,r\i lam'►Sc_cs•V&t l 2.col ZOOS Form 103 Rev 1/2011 Page 3 of 5 1 Rev 12011 Page 2 of 5 le An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper • MANAGER'S LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE • FROM TO NUMBER 2008 2011 Nash Finch Co. Christopher Brown (952) 832-0534 2008 2008 McLane International Michael Julian (281) 210-3295 MANAGER AND SPOUSE MUST REVIEW AND ANSWER THE QUESTIONS BELOW Please print clearly 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. 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 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) 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. Baker's Supermarkets • 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? DYES ONO 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) *YES ENO • Form 103 Rev 1/2011 Page 4 of 5 1 '11 E:EittE 4 y PERSONAL OATH AND CONSENT OF INVESTIGATIOWP 2 8 2011 NEHRAEKALIOUOR CONTROL COMI,i>I IISSIOIR 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. f/(;),...4:01.&uvz Signature of an ppli n Signature of Spouse ACKNOWLEDGEMENT State of Neb a County of ��n,nn n The foregoing instrument was acknowledged before me this SC1P- �, V)Shrl UVUS date name of person acknowledged Affix Seal GENERAL NOTARY-State of Nebraska • Notary Public signature I JAMIE HAWK . My Comm.Exp.June 5,2013 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 1/201 1 Page 5 of 5 .Print Form SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION • 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX:(402)471-2814 Website: www.Icc.ne.gov I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any interest, directly or indirectly in the operation or profit of the business(§53-125(13))of the Liquor Control Act. I will not tend bar,make sales, serve patrons,stock shelves,write checks, sign invoices or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be required;however, I am obligated to sign and disclose any information on all applications needed to process this application. ROBIN STINEBAUGH Signature of spo c king for waive Printed name of spouse asking for waiver (Spouse of individual listed below) State of Nuoiray_0( County of 5C1 The foregoing instrument was acknowledged before me this StPt(Altkiaa 2, 72 I by ?D7\V T1 rt ioGuo Y I date name of person ackno`uledged Affix Seal -State of Notaryiublic signature GENERAL NOTARY JAMIE HAWKbraska 111 My Comm.Exp.June 5,2013 1 acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-I25(13))the Commission may cancel or revoke the liquor license. L& s1)/4G1� ig ature of individua • volt' with application Printed name of applying individual (Spouse of individual listed above) State of MOVIC-241 County of The foregoing instrument was acknowledged before me this 201 t by I io V VI S ModA Y date name of person acknowledged ll Affix Seal Notary ublic signature GENERAL NOTARY-State of Nebraska g lI HAW w ..,}. s My Comm.JAMIE H. June 5K,2013 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 • City of Omaha, Nebraska 1819 Farnam—Suite LC 1 wri Omaha, Nebraska 68183-0112 o � pp _ Buster Brown (402) 444-5550 �s0 N' City Clerk FAX (402) 444-5263 4 i: :o �BR�Is+ October 12, 2011 Bag N Save, Inc. Application to appoint Louis Stinebaugh Dba"Bag N Save" manager of your present Class "C" 3003 North 108th Street Liquor 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 October 25, 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, A'4'4 .G-4., Buster Brown City Clerk BJB:clj gnature GENERAL NOTARY JAMIE HAWKbraska 111 My Comm.Exp.June 5,2013 1 acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-I25(13))the Commission may cancel or revoke the liquor license. L& s1)/4G1� ig ature of individua • volt' with application Printed name of applying individual (Spouse of individual listed above) State of MOVIC-241 County of The foregoing instrument was acknowledged before me this 201 t by I io V VI S ModA Y date name of person acknowledged ll Affix Seal Notary ublic signature GENERAL NOTARY-State of Nebraska g lI HAW w ..,}. s My Comm.JAMIE H. June 5K,2013 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 City of Omaha, fi'1ebraski J 'i01:44)-- tti 1819 Farnam—Suite LC 1 n® zjlp Omaha, Nebraska 68183-0112 0� Buster Brown (402) 444-5550 A City Clerk FAX (402) 444-5263 o4TWD rEB0t44 October 12, 2011 Louise Stinebaugh Application to be appointed manager of the present 16570 Sage Street Class "C" Liquor Licenses and Package Liquor Licenses Omaha, NE 68136 for Bag N Save, Inc. (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 October 25, 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, qi.or e 60"/4:°) Buster Brown City Clerk BJB:clj 111 My Comm.Exp.June 5,2013 1 acknowledge that I am the spouse of the above listed individual. I understand that my spouse and I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-I25(13))the Commission may cancel or revoke the liquor license. L& s1)/4G1� ig ature of individua • volt' with application Printed name of applying individual (Spouse of individual listed above) State of MOVIC-241 County of The foregoing instrument was acknowledged before me this 201 t by I io V VI S ModA Y date name of person acknowledged ll Affix Seal Notary ublic signature GENERAL NOTARY-State of Nebraska g lI HAW w ..,}. s My Comm.JAMIE H. June 5K,2013 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 O '-P .0 o o r n u, °� o, cra o CDtri � a z CD •-- nt-' ov' N O4d p) 0 0o A'CD , \� 3 • cr) P ''• N w ,n nCd ri' CD CDw o EnCD •-no. o �, o 0