RES 2011-1267 - Appoint Louis E Stinebaugh manager of Bag N Save •
. ,, �.;�,,% { - ` 1 STATE OF NEBRASKA
•
Dave Heineman NEBRASKA LIQUOR CONTROL COMMISSION
\'s i4 Governor S { t ' Hobert B. Rupe
R �6� t Executive Director
301 Centennial Mall South,5th Floor
P.O.Box 95046
C IT r C I.. Lincoln,Nebraska 68509-5046
O l:M A U irl• )\I F_=;P.A ;;< + 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-64667, C-64666, D-57629, C-91109, C-91111, D-28377, C-64665, C-
64673, D-9111S0
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
le 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,
-taelk, -7 €0-tIA-
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
ur S �_ 5' /403)4Gf�
ig ature of individua• volv with application Printed name of applying individual
(Spouse of individual listed above)
State of WA04--61
County of The foregoing instrument was acknowledged before me this
211, 1 by____L_,Egs__-,-_sb-ivto,Ap
date name of person ackpowledged
Affix Seal
Notary ublic signature ql�',I GENERAL NOTARYJAMIE State of Nebraska
• HAWK
✓ ;: My Comm.Exp.June 5,2013
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
advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
MANAGER APPLICATION Office Use
INSERT -FORM 3c
.01
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH SEP 2 8 2011
PO BOX 95046 4E Th J�,tt,0�
LINCOLN, NE 68509-5046
PHONE: (402)471-2571 CtaNTi,:t/t,t;1/4) i0il:S4i(IN
FAX: (402) 471-2814
Website: www.lcc.ne.govC py
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:91110
(if new application leave blank)
Premise Trade Name/DBA: Bag N Save
Pr treet Address: 1826 Vinton Street
City: Omaha State:NE Zip Code:68102
Premise Phone Number: (402)346-7487
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
CORPS; e TE hF10EMBER SIGNATURE
(Faxed signatures are acceptable)
Form 103
Rev 1/2011
Page 2 of 5
missioner Chairman Commissioner
cc: file
An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
ur S �_ 5' /403)4Gf�
ig ature of individua• volv with application Printed name of applying individual
(Spouse of individual listed above)
State of WA04--61
County of The foregoing instrument was acknowledged before me this
211, 1 by____L_,Egs__-,-_sb-ivto,Ap
date name of person ackpowledged
Affix Seal
Notary ublic signature ql�',I GENERAL NOTARYJAMIE State of Nebraska
• HAWK
✓ ;: My Comm.Exp.June 5,2013
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
advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
Manager's information must be completed below PLEASE PRINT CLEARLY
ii i W
Gender: MALE fl FEMALE
Last Name:
Stinebaugh
First Name: Louis SEP 2 8 2011 E
MI:
Home Address (include PO Box if applicable):
16570 Sage Street CONTRtiLGl2fJiiiAllSSiON
City: Omaha County: Douglas 68136
Zip Code:
Home Phone Number: (262) 227-7559 Business Phone Number: (402) 885-7899
NE
Social Security Number: Drivers License Number& State:
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)
❑■ YES ❑NO
'Spouse's information
Spouses Last Name: Stinebaugh First Name: Robin MI: D
Social Security Number: Drivers License Number& State: "
Date Of Birth: Place Of Birth: Shawnee, Oklahoma
•APPLICANT& SPOUSE MUST LIST RESIDENCE(S) FOR THE PAST TEN(10) YEARS
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
�O�S(V�Ci-P1 AA)i SCQriSiv1 2 00 t 260(o 1c�ouSrYlQ►t U conc 260I Z°(io
Form 103
Rev 1/201 1
Page 3 of 5
r Chairman Commissioner
cc: file
An Equal Opportunity/Affirmative Action Employer
Printed with soy ink on recycled paper
ur S �_ 5' /403)4Gf�
ig ature of individua• volv with application Printed name of applying individual
(Spouse of individual listed above)
State of WA04--61
County of The foregoing instrument was acknowledged before me this
211, 1 by____L_,Egs__-,-_sb-ivto,Ap
date name of person ackpowledged
Affix Seal
Notary ublic signature ql�',I GENERAL NOTARYJAMIE State of Nebraska
• HAWK
✓ ;: My Comm.Exp.June 5,2013
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
advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
_+ 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 parr please list
charges by each individual's name. FiE"'aalvl
❑ YES ❑ NO
tit
If yes, please explain below or attach a separate page. SEP 2 8 2011
Name of Applicant Date of Where Description of ChmlyEASVOE I(;( osition
Conviction Convicted
(mm/yyyy) (city &state) COtNTR )LCOMillIIISSION
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state? OYES ONO
IF YES, list the name of the premise.
Bakers 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? EYES 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)
OYES ONO
Form 103
Rev 1/2011
Page 4 of 5
The foregoing instrument was acknowledged before me this
211, 1 by____L_,Egs__-,-_sb-ivto,Ap
date name of person ackpowledged
Affix Seal
Notary ublic signature ql�',I GENERAL NOTARYJAMIE State of Nebraska
• HAWK
✓ ;: My Comm.Exp.June 5,2013
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
advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
PERSONAL OATH AND CONSENT OF INVESTIGATION
The above individual(s), being first duly sworn upon oath, deposes and states tl the unders.ignedNis the
applicant and/or spouse of applicant who makes the above and foregoing applicatigailTAMeLion 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 §53-131.0])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.
RoApc, ,L- 23L,y,_its4
7. :2c‘ o,
S gnature of a s p i nt Signature of Spouse
ACKNOWLEDGEMENT
State of Nebrl
County of The foregoing instrument was acknowledged beforen me this
by �i U l 04A )3 1 1 be�X,tI
date name of person acknowledged
Affix Seal GENERAL NOTARY-State of Nebraska
Notary Public signature JAIMIIE HAWK
t 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 1/2011
Page 5 of 5
Notary ublic signature ql�',I GENERAL NOTARYJAMIE State of Nebraska
• HAWK
✓ ;: My Comm.Exp.June 5,2013
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
advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
,Print Fbrm I
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.lcc.ne,gov
I acknowledge that Ian the spouse of a liquor license.holder. My s.ignature bell*'cor f rms 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 irivoices•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�fngerprint will'not be
ev required; hower, mil.a obligated to sign and disclose any information on all;applications needed to,process this
application. • '
I,0 ROBIN STINEBAUGH
Signature of spo c king for waive Printed name of spouse asking for waiver
(Spouse of individuallisted below)
State of 'iW.__.0(
County of 5VPU1 The foregoing instrument was acknowledged before me this
aPtUltklail( O I by 27\V t C - I f UvY JIM�t�.
date name of person acknoV edged
4 `(n /���I/VV� Affix Seal
GENERAL NOTARY-State of Nebraska
Notary public signature JAMIE HAWK
J ` My Comm.Exp.June 5,2013
.��+-x ate**-.
I acknowledge;that lam the spouse of the above listed individual: T undei'stand t11at,'my`spousse and I are.responsible for
compliance-with the conditions set out above. If it is.determined,that the above.individual has violated,(§53-125(13))the
Commission ma cancel or revoke the liquor license: . r �\ • •
Y _. . . . q tea: .,. '�...
L 6 V F_ 5' ,-( . Gt�
ig ature of individua•. volv with application Printed name of applying individual
(Spouse of individual listed above)
State of Ra0V61
County of The foregoing instrument was acknowledged before me this
(ZIA 1 by I ,t)Uit S )�(k
date name of person acknowledged
Affix Seal
Notary ublic signature GENERAL NOTARY-State of Nebraska
JAMIE HAWK
my Comm.Exp.June 5,2013
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
e the alternate format.
FORM 35-4178
Revised 1/2008
94)
Cityo f Omaha, Webraikj 4. 1swift.4101.11%7
tipof� .�
1819 Farnam—Suite LC 1 �®► � Ij; '^
Omaha, Nebraska 68183-0112 o ,; _. _:-�
Buster Brown (402) 444-5550 144,
City Clerk FAX (402) 444-5263 044.D FEBg°AA
• October 12, 2011
Bag N Save, Inc. Application to appoint Louis Stinebaugh
Dba"Bag N Save" manager of your present Package
1826 Vinton Street Liquor License location
Omaha,NE 68102
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,
Buster Brown
City Clerk
BJB:clj
June 5,2013
.��+-x ate**-.
I acknowledge;that lam the spouse of the above listed individual: T undei'stand t11at,'my`spousse and I are.responsible for
compliance-with the conditions set out above. If it is.determined,that the above.individual has violated,(§53-125(13))the
Commission ma cancel or revoke the liquor license: . r �\ • •
Y _. . . . q tea: .,. '�...
L 6 V F_ 5' ,-( . Gt�
ig ature of individua•. volv with application Printed name of applying individual
(Spouse of individual listed above)
State of Ra0V61
County of The foregoing instrument was acknowledged before me this
(ZIA 1 by I ,t)Uit S )�(k
date name of person acknowledged
Affix Seal
Notary ublic signature GENERAL NOTARY-State of Nebraska
JAMIE HAWK
my Comm.Exp.June 5,2013
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
e the alternate format.
FORM 35-4178
Revised 1/2008
ots„,,,HA,
_ _
• Cityo Omaha Nebras a 101 ,
i(1' 711*4111"1"
1819 Farnam—Suite LC 1 ��WvO� t
Omaha, Nebraska 68183-0112 0'
Buster Brown (402) 444-5550 .o �
City Clerk FAX (402) 444-5263 04, r�B��hi-
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:
q g
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,
4460"Aer,„2,
Buster Brown
City Clerk
BJB:clj
ouse of the above listed individual: T undei'stand t11at,'my`spousse and I are.responsible for
compliance-with the conditions set out above. If it is.determined,that the above.individual has violated,(§53-125(13))the
Commission ma cancel or revoke the liquor license: . r �\ • •
Y _. . . . q tea: .,. '�...
L 6 V F_ 5' ,-( . Gt�
ig ature of individua•. volv with application Printed name of applying individual
(Spouse of individual listed above)
State of Ra0V61
County of The foregoing instrument was acknowledged before me this
(ZIA 1 by I ,t)Uit S )�(k
date name of person acknowledged
Affix Seal
Notary ublic signature GENERAL NOTARY-State of Nebraska
JAMIE HAWK
my Comm.Exp.June 5,2013
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
e the alternate format.
FORM 35-4178
Revised 1/2008
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