RES 2004-1450 - Appoint John M Feddin to Billy Frogg's Grill & Bar West STATE OF NEBRASKA
"s sr"'Ta RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION
�• !.� Hobert B. Rupe
47kk <�: ';2' 1t c1 ! Executive Director
H p'% r On 13 301 Centennial Mall South,5th Floor
e __
� _.,. - P.O.Box 95046
44 u ,l ;a ��, -1`�tl Lincoln,Nebraska 68509-5046
iU. _ (. fi EN E C ti��\A Phone(402)471 2571
11 .......... 0 = J�f Ai 4k„l
1 ' = Fax(402)471-2814
TRS USER 800 833-7352(TTY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor
October 15, 2004
Omaha City Clerk
Omaha/Douglas Civic Center
1819 Farnam St
Omaha NE 68183
Clerk:
Enclosed is a copy of the manager application for John M. Feddin in connection
with the Class C license#36187 for OMG, Inc dba Billy Frogg's Grill &Bar West, located
at 8724 West Dodge Rd, Omaha,NE 68114. Please present this application to your City
Council and send us the results of that action.
• Also enclosed, for your information, is a corporate form showing the restructure
of OMG Inc, so that John Feddin is acquiring 497 shares of stock with an affidavit of non-
participation filed by spouse, Mehrzad M. Yazdchi-Nejad Feddin.
NEBRASKA LIQUOR CONTROL COMMISSION
Mary Messman
Licensing Division
mm
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
. ' 35-4013 Page 1 of 4
Application for Corporate Manager .
*Must Be A Nebraska Resident*
Please submit in Triplicate
Return to: Nebraska Liquor Control Commission,PO Box 95046
301 Centennial Mall So.,Lincoln NE 68509
Phone:(402)471-2571 Fax: (402)471-2814 Web address: http://www.nol.org/home/NLCC/
Required areas marked by a red asterisk(* )
LIQUOR LICENSE INFORMATION
Name of Licensed Corporation Class&License number
10MG, Inc. . * IC 36187 *
Trade Name of Licensed Premise
'Billy Frogg's Grill & Bar West *
Street Address of Licensed Premise City County
18724 West Dodge Road * 'Omaha * 'Douglas *
On behalf of the corporation,I designate this individual as corporate manager.
Signature of Corporate President/CEO: )( 1 l` / Y ` ,,,......--
APPLICANT INFORMATION(MUST BE 21 OR OVER)
Full Name(Last,First,Middle,Maiden) Sex Social Security Number
John M. Feddin ' * F M
_. .. ..
Date of Birth Place of Birth
Isfahan, Iran
Home Street Address City r Cp / � F
12839 Eagle Run Drive * 10maha Dou g las -'
State Zip Code Home Telephone Number
ENE * 168164 * 1402-493-1946 *
Business Telephone Number Drivers License Number State
1402-397-5719 * * 1NE *
I
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• 35-4013 Page 2 of 4
Are You Married? * Yes r No C If Yes,You must :complete the following:
g
SPOUSE'S INFORMATION (IF NOT MARRIED INDICATE)
Full Name(Last,First, Middle,Maiden) Social Security Number
IMehrzad M.Yazdchi-Nejad Feddin F
Drivers License Number
State Date of Birth
INE '
Place of Birth
IRasht, Iran
* 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 criminal
charge.Criminal charge means any charge alleging a felony or misdemeanor violation of a federal or state law; or 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
C'
* 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.
Yes No
John M. Feddin, Manager of Twice, Inc. (approximately 12 years ago)
John M. Feddin, Manager of Feddin, Inc. (approximately 14 years ago)
* 3.Have you or your spouse ever made a compromise settlement for violation of such laws?
Yes No
* 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)
Yes No
f' C
* 5.Have you filed fingerprint cards and PROPER FEES(if check,make out in ai '. tate 1 tv
application? :. -''. ;1 "j,`.,,
Yes No
{; C 4 J4
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35-4013 Page 3 of 4
RESIDENCES FOR PAST 10 YEARS,APPLICANT AND SPOUSE MUST COMPLETE
Year
From To
Applicant:City&State
I
1..
Spouse: City&State
Year
From To
Applicant:City& State
Spouse:City&State �—`--
1 1 1
Year
From To
Applicant: City& State
Spouse: City& State
...... I 1
Year
From To
Applicant: City& State
6336 North 10-9 Plaza, Omaha, NE 68164 I ; I
Spouse:City&State
. l
EMPLOYERS -LIST LAST TWO EMPLOYERS
Year
Name of Employer From To
OMG, Inc. 11991 `IPresen
Name of Supervisor Telephone Number
Lloyd T. Harmsen 1402-397-5719
Year
Name of Employer From To
Name of Supervisor Telephone Number
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P g 10/7/2004
• 35-4013 Page 4 of 4
PERSONAL OATH AND CONSENT OF INVESTIGATION - MUST BE SIGNED BY
APPLICANT & SPOUSE
STATE OF NEBRASKA )
) SS •
COUNTY OF DOUGLAS )
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,an affidavit may be attached,however,fingerprint
cards are still required to be filed.
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 and inaccurate.
Signature-of Applican a ~ Signature of Spouse(if applicable)
Subscribed in my presence and sworn to before me this Subscribed in my presence and sworn to before me this
8 day of {3_:1 i •:�OtI • day of
fi Notary Signature&Seal Notary Signature&Seal
GENERAL NOTARY-State of Nebraska
I' JONI S.NEGUS
_.v. My Comm.bp.March 2,2006Wenfynd Print
FORM 35-4013
REV. 2/01
1 �:›.if r .a e.7c ','T__-SI'A g F:M \
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•
NEBRASKA LIQUOR CONTROL COMMISSION
AFFIDAVIT OF NONPARTICIPATION
The undersigned individual acknowledges that he/she will have no interest, directly or indirectly, in the
operation or profit of the business, as prescribed in Section §53.125(13) of the Liquor Control Act. Such
individual shall not tend bar, make sales, serve patrons, stock shelves, write checks, sign invoices,
represent themselves as owner or in any way participate in the day-to-day operations in any capacity.
Undersit, red Will also be.waived of filing fingerprint cards,however, has disclosed any violation(s) on the
application.
Mehrzad . Feddin, Signature of Spouse
SUBSCRIBED in my presence and sworn to before me this day of October, 2004.
"i% ; •.. DAWN M,DRIES.
0ENE11µ.*_ MY COMMISSION WAD
=%' Ottoimi4 20O6 Signature of Notary Public
The licensee/applicant understands that he/she is responsible for compliance with the conditions set out
above, and that if such terms are violated, the Commission may cancel or revoke the license.
OMG,.INC., OMG,INC.,
A Nebraska Corporation A Nebraska Corporation
-�_ f • • / Llo d T. Elarrnsen President —__—.-
Lloyd T. I-Iarmset5,President .' Print Name of Licensee/Applicant
Signature of.Licensee/Applicant
SUBSCRIBED in my presence and sworn to before me this day of October, 2004.
•
Sigrtatu(e of Notary Public C
tirt
GENERAL NOTARY-State of Nebraska
4! JONI S.NEGUS
• E My Comm_Erp..March 2,2006
.3 •
FORM 35-4178
REV 2/01
,
' 35-4183 Page 1 of 3
s -
Corporation/LLC Application for License - Form 3
Nebraska Liquor Control Commission
INSTRUCTIONS:
Application and application for manager must be typewritten and submitted in triplicate " —��Vit,-
1)
2 Fingerprint cards cardsper person)must be submitted for: a)each stockholder owning
g �P (2 � ��
over 25%of the stock,b)chief executive officer,c)proposed manager and d)all spouses CC/ 1
4 3)Information regarding spouses must be completed 7�Jn-r
Required areas marked by a red asterisk( ) -L f?i r
Name of Corporation That Will Hold License. Attach copy of Articles of Total Number of Shares(if `.4 lN
Incorporation corporation)
JOMG, Inc. * 1710 *
Corporate Street Address Mailing address for receipt of Liquor Control Commission Mailings
18724 West Dodge Road * 18724 West Dodge Road *
City County State
Corporate Telephone Number Omaha !Douglas NE Zip Code
402-397-5719 * * * * 168747 * -
Name of Registered Agent Name of Proposed Manager
'Ronald L. Eggers * !John M. Feddin *
IN THIS SECTION LIST THE NAME OF THE CHIEF EXECUTIVE OFFICER
Name Title Date of Birth
[Lloyd T. Harmsen * )CEO/President * *
Social Security Number Home Address(1) City
11807 South 76th Avenue * !Omaha *
State Zip Code Home Telephone Number
1NE , * 168124 ; * -I 1402-397-8265 *
PRINCIPLE OFFICERS,DIRECTORS,STOCKHOLDERS,MEMBERS AND SPOUSES
Name of Officers,Directors,Members and Spouses. Social Security
Give Last Name,First Name,Middle,Maiden,and Number Date of Birth Title
any aliases
Name
ILloyd T. Harmsen __ i 10EO/President
Spouse Name
N/A I 1 r
. .
Partner Number of Shares/%1 497 . Spouse Number of Shares/% N/A
Name of Officers,Directors,Members and Spouses.
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35-4183 Page 2 of 3
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Give Last Name,First Name,Middle,Maiden,and Social Security
any aliases Number Date of Birth Title
Name
John M. FeddinVP/Secretary/Treasure.
Spouse Name
1Mehrzad M. Yazdchi-Nejad Feddin !None
Partner Number of Shares/%7371 Spouse Number of Shares/%
Name of Officers,Directors,Members and Spouses. Social Security
Give Last Name,First Name,Middle,Maiden,and Number Date of Birth Title
any aliases
Name
.. .
Spouse Name
. ... .
Partner Number of Shares/% Spouse Number of Shares/%I
• Name of Officers,Directors,Members and Spouses. Social Security
Give Last Name,First Name,Middle,Maiden,and Number Date of Birth Title
any aliases
Name
Spouse Name
Partner Number of Shares/%1 Spouse Number of Shares/%I
Name of Officers,Directors,Members and Spouses. Social Security
Give Last Name,First Name,Middle,Maiden,and Number Date of Birth Title
any aliases
Name
I_ _ l
Spouse Name
Partner Number of Shares/% Spouse Number of Shares/%
(If Necessary,Continue on Separate Sheet)
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• 35-4183 Page 3 of 3
Is this Corporation/LLC controlled by another Corporation?
Yes r. No (:
iName of control Corporation
If YES,LIST EACH STOCKHOLDER/MEMBER OWNING MORE THAT 25%stock/interest in that corporation/LCC.
Any applicant who has a Corporation as a shareholder MUST file an organizational chart listing all shareholders and/or
corporations owning more than 25%stock and listing of the percentage of stock owned.
Please indicate below your corporate tax year with the IRS
Starting date:101/01 Ending date: 12/31
State of Nebraska )
) ss.
Douglas County )
Y
Nary Public Signature&'-Eleal Pres ent/Member
I GENERAL NOTARY
JONIS.NE-State GUSof Nebraska
My Corm•Exp.March 2,2006
In Compliance with ADA,this form is available in other
formats for persons with disabilities.A ten day advance
period is requested in writing to produce the alternate Secretary/Member
format.
'Ver fyo mand'Print
FORM 35-4183
RECEIVE,,.
REV. 02/01
Gi' 14 2004
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