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RES 2007-0489 - Appoint Delbert Carlson manager of Kwik Shop #690 TKT T� Oy Lev:` / ''•'�'li y =' STATE OF NEBRASKA y m;'J!--i 914.�.�a ,, Dave Heineman a .v �, NEBRASKA LIQUOR CONTROL COMMISSION i Governor t Rupe B. Ru e r 9R s,_— Executive Director 301 Centennial Mall South,5th Floor t tjt_a_;',;t P.O.Box 95046 iEliRASKA Lincoln,Nebraska 68509-5046 Phone(402)471-2571 Fax(402)471-2814 TRS USER 800 833-7352(TTY) web address:http://www.lcc.ne.gov/ March 29, 2007 Omaha City Clerk 1819 Farnam Street LC1 Omaha NE 68183 Dear Clerk: • Enclosed is a copy of a manager application for Delbert Carlson in connection with • Kwik Shop Inc dba Kwik Shop #690, located at 3428 S 42nd Street, Omaha NE. Please present this application for manager to your Council and send us the results of their action. Sincerely, NEBRASKA LIQUOR CONTROL COMMISSION n CeU Jeri Cash Licensing Division jc encl. cc: file • Rhonda R. Flower Bob Logsdon R.L. (Dick)Coyne. Commissioner Chairman Commissioner An Equal Opportunity/Affirmative Action Employer Printed with soy ink on recycled paper Signature of Notary Public MY COMMISSION EXPIRES May 11.2007 FORM 35-4178 REV 2/01 o before me this—'2 Subscribe 'n my presence and sworn to before me this q day of Jt e(Ch. 2-OO'"l . day of e(C h 2O01 . Notary Signa & eal )tart' ignature&Seal • FORM 35-4013 REV.4105 09/97 10/03 Godfathers Pizza Jeff Ward 402-391-0656 • FORM 35-4013 REV.4/05 : 'iiap11111 n�'.at nrotnnls�`�' MY COMMISSION EXPIRES' MY COMMISSION EXPIRES' May 11,2007 May 11,2007 • FORM 354013 REV.4/05 • • FORM 35-4013 I REV.4/OS 1 ' REV.4/05 .........r..:.......Y.{........ v. ..........r....v:.x........4..,,v;.v;;....v.v::::::::n....r.......... ..........v.v.t._v{.:ii}?::n:�:•:::.::::::::::.:.r::.:::::.v:::v:::::n.:....n:..::y?:::..:iv'i::v'-w::at: r.n.xv:nh:.:y.:3::::::.......................{v,.::............:...v:::::::::::.v::N:.w:::::.............,,, ..... v::•::v.{.nn.. ..v::•,.�{:+�:::}w:::::.v:::::::.v\w:::.v:::::::v.. ............�.......... ...........................................::.::::::.::.:::.::.:yi:W:::::v.,.::::::::-::::::x{^:4:L:{:::::..::. YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO �-- (0)6, - a45, S4('vfLir' i Mon-�°1�1q� �.PM�Qh LWi� t,...eST- (1oL -3 �1 •,.5 ?3, Sl Z-GI 2-- rSENtOt S'�t :..::...:.:....... .:.::.:..:.:: STATE OF NEBRASKA ) • ) SS COUNTY OF ) The above individual(s),being fast 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,an 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 ifthe information contained herein is incomplete and inaccurate. Signature of Applicant Signature of Spouse(if applicable) Subscribed in mypresence and sworn to before me this BQ (P � Subscribed in my presence and sworn�before me this day of a►2Ct ay B day of • �c Notary Si nature&Seal Notary Signature&Seal GatERe t.AWRY-Rit3 of Netx a a. STEPHEN D. FORM 35 4013 Phi COMM.NI REV.2/01 PAGE 2 ( 1 �, APPLICATION FOR LIQUOR LICENSE r , -, ,-_ _ CORPORATION MANAGER-FORM 3b i a-,�`�r i _L) *MUST BE A NEBRASKA RESIDENT* 301 CENTENNIAL MALL SOUTH i<tr O 2007 PO BOX 95046 LINCOLN,NE68509.5046 NEBRASKA LIQ1!OR PHONE:(402)471-2571 FAX:(402)471-2814 et'‘'t r+ ;i r,J i;/Il„Ls,,,1` lip' Website:http:/iwww.lcc.ne.gov/ �Lg UOR W. ..� .�...�.�_ <_.�NSE_THE+OR1VIr1P:ON..... .�.__._ ;,, ..: ._ .�_.: _.._._ '_._.._.:, NAME OF LICENSED CORPORATION Kwik Shop Inc. CLASS&LICENSE NUMBER D67242 TRADE NAME Kwik Shop#690 STREET ADDRESS 3428 South 42nd Street CITY Omaha Al �1ND IR•S�41�/// ,��'GENERq��'��; w 1 SIGNATURE OF C\II P PREt� ichael Hoffmann,. President Kwik Shop, Inc. APPLICANT:INFORMATION:,(MUSW E ,jgaj AND NEBRASKA RESIDENT) May 11,2007 NAME Delbert Darrel Carlson ADDRESS 821 N 47th Street,Apartment#8 CITY Omaha STATE NE ZIP CODE 68132 HOME PHONE NUMBER(402)445-0097 BUSINESS PHONE NUMBER(402)391-0676 SEX MALE 0 FEMALE SOCIAL SECURITY NUMBER _ 1 DATE OF BIRT ' - PLACE OF BIRTH Neligh, Nebraska DRIVERS LICENSE NUMBER&STATE Nebraska ' , ST'0:VSLS Tn ?.M.V.--VONXI NDT MA Ti E TNDIaATE :.-----.'= -_.::. E: _ _ --.--- _ ._:_1 SPOUSE NAME Not Married SOCIAL SECURITY NUMBER DATE OF BIRTH DRIVERS LICENSE NUMBER&STATE FORM 35-4013 REV.4/05 day of e(C h 2O01 . Notary Signa & eal )tart' ignature&Seal • FORM 35-4013 REV.4105 09/97 10/03 Godfathers Pizza Jeff Ward 402-391-0656 • FORM 35-4013 REV.4/05 : 'iiap11111 n�'.at nrotnnls�`�' MY COMMISSION EXPIRES' MY COMMISSION EXPIRES' May 11,2007 May 11,2007 • FORM 354013 REV.4/05 • • FORM 35-4013 I REV.4/OS 1 ' REV.4/05 .........r..:.......Y.{........ v. ..........r....v:.x........4..,,v;.v;;....v.v::::::::n....r.......... ..........v.v.t._v{.:ii}?::n:�:•:::.::::::::::.:.r::.:::::.v:::v:::::n.:....n:..::y?:::..:iv'i::v'-w::at: r.n.xv:nh:.:y.:3::::::.......................{v,.::............:...v:::::::::::.v::N:.w:::::.............,,, ..... v::•::v.{.nn.. ..v::•,.�{:+�:::}w:::::.v:::::::.v\w:::.v:::::::v.. ............�.......... ...........................................::.::::::.::.:::.::.:yi:W:::::v.,.::::::::-::::::x{^:4:L:{:::::..::. YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO �-- (0)6, - a45, S4('vfLir' i Mon-�°1�1q� �.PM�Qh LWi� t,...eST- (1oL -3 �1 •,.5 ?3, Sl Z-GI 2-- rSENtOt S'�t :..::...:.:....... .:.::.:..:.:: STATE OF NEBRASKA ) • ) SS COUNTY OF ) The above individual(s),being fast 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,an 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 ifthe information contained herein is incomplete and inaccurate. Signature of Applicant Signature of Spouse(if applicable) Subscribed in mypresence and sworn to before me this BQ (P � Subscribed in my presence and sworn�before me this day of a►2Ct ay B day of • �c Notary Si nature&Seal Notary Signature&Seal GatERe t.AWRY-Rit3 of Netx a a. STEPHEN D. FORM 35 4013 Phi COMM.NI REV.2/01 PAGE 2 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. DYES ONO If yes,please explain below or attach a separate page. Misdemeanor- 10/1998 -MIP in Boone County / Misdemeanor- 03/2000 -MIP in Wayne County 2. Have you or your spouse ever made application for any liquor license or manager for any liquor license? IF YES,for what premise give license number and date. OYES jNO 3. Have spouse your or yous .se ever made a compromise settlement for violation of such laws? P P .DYES LINO 4. Do you,as a manager,have all the qualifications required by any person entitled to hold a Nebraska Liquor License? Nebraska Liquor Control Act(§53-131.01) EjYEs DNO • 5. Have you filed fingerprint cards and PROPER FEES(if check,make out to the NE State Patrol),with this application? fI2 YES ONO RESIDENCES TOR:THE>PAST/.10:YEA'RS;APPLICANT;AND;SPOUSE MUST.'COMPLETE APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR FROM TO FROM TO Omaha, Nebraska 2006 Present No Spouse Norfolk, Nebraska 2005 2006 Lincoln, Nebraska 2004 2005 Applicant Wayne, Nebraska 1998 2004 Albion, Nebraska 1997 2004 EMPLOYERS 'LAST:TWO`EMPLOYERS MONTH/YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO 01/06 03/06 Great Dane Trailers John Hancock (402) 375-5500 01/05 01/06 Aureus Financing & Accounting Tamara 402-464-4488 • FORM 35-4013 REV.4/05 1 FORM 35-4013 I REV.4/OS 1 ' REV.4/05 .........r..:.......Y.{........ v. ..........r....v:.x........4..,,v;.v;;....v.v::::::::n....r.......... ..........v.v.t._v{.:ii}?::n:�:•:::.::::::::::.:.r::.:::::.v:::v:::::n.:....n:..::y?:::..:iv'i::v'-w::at: r.n.xv:nh:.:y.:3::::::.......................{v,.::............:...v:::::::::::.v::N:.w:::::.............,,, ..... v::•::v.{.nn.. ..v::•,.�{:+�:::}w:::::.v:::::::.v\w:::.v:::::::v.. ............�.......... ...........................................::.::::::.::.:::.::.:yi:W:::::v.,.::::::::-::::::x{^:4:L:{:::::..::. YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO �-- (0)6, - a45, S4('vfLir' i Mon-�°1�1q� �.PM�Qh LWi� t,...eST- (1oL -3 �1 •,.5 ?3, Sl Z-GI 2-- rSENtOt S'�t :..::...:.:....... .:.::.:..:.:: STATE OF NEBRASKA ) • ) SS COUNTY OF ) The above individual(s),being fast 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,an 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 ifthe information contained herein is incomplete and inaccurate. Signature of Applicant Signature of Spouse(if applicable) Subscribed in mypresence and sworn to before me this BQ (P � Subscribed in my presence and sworn�before me this day of a►2Ct ay B day of • �c Notary Si nature&Seal Notary Signature&Seal GatERe t.AWRY-Rit3 of Netx a a. STEPHEN D. FORM 35 4013 Phi COMM.NI REV.2/01 PAGE 2 ., r • ♦ • PERSONAL OATH AND CONSENT OF INVESTIGATION MUST BE SIGNED BY APPLICANT& SPOUSE 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 hank 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,an affidavit of non participation maybe 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. Signatureo Applicant Delbert D. CarlsonSignature of Spouse Subscribed i y presence and sworn to before me this Subscribed in my presence and sworn to before me this day of n_/n /f(j? _ day of Notary i n e&Seal Notary Signature&Seal 0011nlik 1tQ l Ay s3E �•• MY COMMISSION EXPIRES May 11,2007 • • FORM 35-4013 REV.4/05 y 01/06 03/06 Great Dane Trailers John Hancock (402) 375-5500 01/05 01/06 Aureus Financing & Accounting Tamara 402-464-4488 • FORM 35-4013 REV.4/05 1 FORM 35-4013 I REV.4/OS 1 ' REV.4/05 .........r..:.......Y.{........ v. ..........r....v:.x........4..,,v;.v;;....v.v::::::::n....r.......... ..........v.v.t._v{.:ii}?::n:�:•:::.::::::::::.:.r::.:::::.v:::v:::::n.:....n:..::y?:::..:iv'i::v'-w::at: r.n.xv:nh:.:y.:3::::::.......................{v,.::............:...v:::::::::::.v::N:.w:::::.............,,, ..... v::•::v.{.nn.. ..v::•,.�{:+�:::}w:::::.v:::::::.v\w:::.v:::::::v.. ............�.......... ...........................................::.::::::.::.:::.::.:yi:W:::::v.,.::::::::-::::::x{^:4:L:{:::::..::. YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER FROM TO �-- (0)6, - a45, S4('vfLir' i Mon-�°1�1q� �.PM�Qh LWi� t,...eST- (1oL -3 �1 •,.5 ?3, Sl Z-GI 2-- rSENtOt S'�t :..::...:.:....... .:.::.:..:.:: STATE OF NEBRASKA ) • ) SS COUNTY OF ) The above individual(s),being fast 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,an 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 ifthe information contained herein is incomplete and inaccurate. Signature of Applicant Signature of Spouse(if applicable) Subscribed in mypresence and sworn to before me this BQ (P � Subscribed in my presence and sworn�before me this day of a►2Ct ay B day of • �c Notary Si nature&Seal Notary Signature&Seal GatERe t.AWRY-Rit3 of Netx a a. STEPHEN D. FORM 35 4013 Phi COMM.NI REV.2/01 PAGE 2 i / q 7 9 ƒ P ) n ) � -I- - \ & o CIL o E q ? m . q 0 7 0 7 n § : ,% / § § k 7 § § / / \ q ƒ /' 0 a z.'zt R 0 § R CD ? o 2 ] 2 .14 . \ \ Uit \ D ƒ , ` / CD °• LA c J 7 [