RES 2004-1492 - Appoint Patrick K Williams manager of Kum & Go #350 STATE OF NEBRASKA
RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION
4Tt;E`sTaTF'�'t
ff,, Hobert B. Rupe
` v / t ' Executive Director
..�.. -, ��I`�0�;1,4 ail'► �•
a 301 Centennial Mall South,5th Floor
' ' l r rj„ P.O.Box 95046
E. �f h y� Lincoln,Nebraska 68509-5046
0�'+�J a
W=B R 4t,S Sc Phone(402)471-2571
y\�\7:1 ftu,t56� - } M l ,r Fax(402)471-2814
5
November 2, 2004 TRS USER 800 833-7352 CITY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor
City Clerk of Omaha
1819 Farnam LC1
Omaha, NE 68183
RE: Manager Application Submittal
Dear Sir/Madam:
The corporation Kum & Go LC DBA Kum & Go #350 has submitted
the enclosed Application for Corporate Manager. The establishment has
the following liquor license(s) Class B #40927 and is located at 1349 Park
Avenue, Omaha, NE 68105 (Douglas County). The applicant's name is
Patrick K Williams.
Please present this application to your City/County Council and return
the results of the action taken to our office. If you have any questions or
comments, please give me a call at (402) 471-4881..
Sincerely,
,i)4, t
Jackie B. Matulka
Licensing Division
Enclosure
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
•
Application for Corporate Manager
*Must Be A Nebraska Resident* C`: l 2 1 2004
Please submit in Triplicate
Return to: Nebraska Liquor Control Commission,PO Box 95046 i '° ? }.
301 Centennial Mall So.,Lincoln NE 68509 '+. ....:Or
Phone:(402)471-2571 Fax:(402)471-2814 Web address:http://www.nol.orgfhome/NLCC/
LIQUOR LICENSE INFORMATION
NAME OF LICENSED CORPORATION CLASS&LICENSE NUMBER
K/� d- fir. G, e. i 9/f,2.7
TRADE NAME OF LICENSED PREMISE
jilAN Go eXc
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
/3 l'i y
On behalf of the corporation,I designate this individual as corporate mana r.
Signature of Corporate President/CEO:
APPLICANT INFORMATION (MUST BE 21 OVER)
NAMF.(LAST,FIRST.MIDDLE,MAIDEN) SEX SOCIAL SECURITY NUMBER DATE OF BI�tTH PLACE OF BIRTH
F I / ,.� ;:(i
�-1Ltextr„s. grra CR Aeli i - - - • • o . / .
HOME STREET ADDRESS CITY COUNTY STATE ZIP CODE
/3L12 �L i.-TSc)nJ ll✓r" Om17fl11 4 &do* 1,4s Ail (61 /b V
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&STATE
0 ) VO2..-99t+ 2,1l97 ( .2 9g0-- 32.2 Rid —
SPOUSE'S INFORMATION(IF NOT MARRIED INDICATE NONE)
FULL NAME(LAST,FIRST,MIDDLE,MAIDEN) SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER
f Z2l s A vr-s— Az'BrZ2 34 G C _
. &STATE
144 11-s" ' /t-x-? C ' - V _ . ^ - ' AVM
DATE OF BIRTH: ` ' PLACE OF BIRTH: .
1
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 penditythe time of this application. If more than one party,please list charges by each individual's name.
❑ YES NO
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.
Li YES NO •
row,';:.4IIr
R I:1'.KM
!WAI
i
0
3. Have you or your spouse ever made a compromise settlement for violation of such laws?
:_ YES -00 UT 2 1 2004
4. Do you,as a manager,have all the qualifications required by any person entitled to hold a Nebraska.Liquor.icepse a' ' -.
Nebraska Liquor Control Act(§53-131.01) ;':. 'f's
YES NO
5. Have you filed fingerprint cards and PROPER FEES(if check,made out to the NE State Patrol),with this application?
:._ YES LE'NO
LIST PRINCIPAL RESIDENCE FOR PAST 10 YEARS,APPLICANT AND SPOUSE MUST COMPLETE
APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
FROM TO FROM TO
661414-1 Ae" 31i Pl( s4/1"e •
S.0 v,i)o N SA /o3 3A 1 Si,'-'
•
EMPLOYERS—LIST LAST TWO EMPLOYERS t
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE NUMBER
FROM TO '/
!o/Ob WO IC ) C. L rr2A ST� Us.I k'ot=',RPL4?L> 7iZ— 32-Y-. .53
(0/0 1 ) (-S- Jv n C o 4I)j 682-osi BLS` 0CZC-- 0 ( Z,-,/
PERSONAL OATH AND CONSENT OF INVESTIGATION—MUST BE SIGNED BY APPLICANT&SPOUSE
STATE OF NEBRASKA )
) SS
COUNTY OF )
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 mule in any part of this
application.the applicantts)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 Ctintrol 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 Bled.
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. ..,/7
Signature of Applicant Signature of Spouse(if applicable)
Subscribed in mry presem:e'and sworn to before me this ./f 7"C/ Subscribed in my preseiRe,and-swgrn to before me this r 7--l'y
day of / day of_- .- _ -.
67161----A/47.- ''''. 1/ i ,'" 7
-: :- ,---7/17..--(W/.7/,;:;
/ Noto Si nalur &Seal
j/ Notary Sign ire&Seal FY g
__ �/ GENERAL(I C Y=Sta' f Nebraska
S GENEi., uTARY-zitate of Nebraska �i;� roast 5.ani'
GINGER GUILFOYLE G y E3 GtJiLFQYLE REV sun
a.rr x„ s M Comm.F.x RAGF:
II't� I �f_.� y p.Jane 10,2007
My Comm.Exp.June 10,2007
s, x :. 014i w;:rt =irw.,,.ts s oci
RECEIVE
OCT 2 12004
NEBRASKA LIQUOR CONTROL COMMISSION
AFFIDAVIT OF NON PARTICIPATION i 1.,.-:.t, c. , =.;..,.<,,..,
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. Undersigned will also be waived of filing fingerprint cards,however, has disclosed any
violati- (s)on application.
f, ,• /1- .` 14,' ,d°-Z—
Signature of Spouse
UBSCRIBED in my presence and sworn to before me this 7tj day of
GENERAL NOTARY-State of Nebraska ter' �' '` 7----d
Ti GINGER GUILFOYLE lC /`j
_ My Comm.Exp.June 10,2007
'gnat e f 1)1` tary 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.
L G. i jam"
Signature of Licensee/Applicant Print Name of Licensee/Applicant
/SJJBSCRIBED in my presence and sworn to before me this 7t day of
/
1( t -L2 .c , ,� C /---; •�
� J /
6:::/1_6;.,----• , / -
GENERAL NOTARY-State of Nebraska ��ig ure of I4ot�arybl is
I GINGER GUILFOYLE / r
My Comm.E .June 10,2007 f 4'
FORM 35-4178
REV 2/01
1
z � oPo 1 o
°c cn n v 0. x
a- cuo fa,.�
wo t) 0
0
n
c) `N 0• P' .Q A.
gib
CfQ
5 e) )".' \
sz) OWE)
q C c - O
nC" — w
1-1
� � o
• 0 "0 w
' "Z
I