RES 2023-0476 - Appoint Ashley N Smith manager of Fas Mart #550V
STATE OF NEBRASKA
Po
%`" . "Wt j Jim Pillen NEBRASKA LIQUOR CONTROL COMMISSION
d;
f ••,,; Governor Hobert B.Rupe
W,` ix -_= Executive Director
y;142 iR�a__- 301 Centennial Mall South
.r_,-
P.O.Box 95046
Lincoln,Nebraska,68509-5046
Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800-833-7352(TrY)
Web Address https://www.lcc.nebraska.gov
Today's Date: April 05, 2023
From: F. Christine Lowery (frances.lowery@nebraska.gov
To: carman.johnson@cityofomaha.org; elizabeth.butler@c
I have attached a copy of a new corporate manager application submitted to the Nebraska
Liquor Control Commission. Please complete the following information below to indicate
your recommendation.
Licensee Name: GPM Midwest 18, LLC
Trade Name (DBA): Fas Mart#550
License Number: B - 116311 •
Manager Name: SMITH, Ashley N
Due Date: June 05, 2023
Z APPROVED
n NO LOCAL RECOMMENDATION
n DENIED •
COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES)
•
#38 RES #2023-0476 MAY 2, 2023
•Clerk's Name: Cy�6' te' Date: May 3, 2023
Kim Lowe Bruce Bailey Harry Hoch
Commissioner Chairman Commissioner
An Equal Opportunity Employer
MANAGER APPLCATION __ . _ _
, FORM 103 RED
NEBRASKA LIQUOR CONTROL COMMISSION License APR ?O2 ''1 301 CENTENNIAL MALL SOUTH
PO BOX 95046 Gass:. .-_+ 01'I3N f`n .rii}.
' LINCOLN,NE 68509-5046 O
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NEBRASRA L =JE;. ;�_?
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PHONE:(402)471-2571 License Number: - ' CONTROL COMM/S ION !J"'�
FAX (402)471 2814 I _ , w
tdes(c(�nebtas$ j vI t n'
EMAILIce fran` a ,A,
WEBSITEr'WWwticc,nebraska gov;- :t - -,— v = 3};
MANAGER MUST::
i :i', Be at least 2I-years of age
Complete all sections of the application.
q • Form must be signed by a:mem[ier ,oreornorate officer.-,
• Include Form 147-Fingerprints are required
4 i:, Provide a copy of one of the following:US birth certificate, US Passport or naturalization papers
• Be a resident of the state of Nebraska and be a registered voter in the State of Nebraska,
-•: Spouse who will participate in the business,the;spouse:mniiistiiieetthe;sameirequirements°s th'ethanager;.
applicant:
Spouse who will not participate in the business
' ° Complete the Spousal Affidavit of Non Participation (Form 116). Beaiirelo eomtilete".boib hal esrof
this form..
�Yto �8� loN w :��_ F 1S ' i "w_ .✓ su rEP ' -1 7 .>
GPM Midwest 18 LLC
Name of Corporation/LLC.:: +
yy
Premises TradeName/DBA:Fas Mart # 550
Premises Street Address:11919 Fort St, ,
Omaha
-City. �COunty . _ — Code: _
Douglas � .� 8164
(40 P ) 431-0491
iP
Premises Phone Number:
lie in nn minvestments.co
Premises Email address: g Vgp m
z
. p /� (4 DD �y-DonaldBasse�f CFO
: to ay.�i $ `i I o:I�D do,�u makt o em T' n AVi _d:1 itt
r-;« w ,.s_. .,_,-7,-.�.c = ace -,,>v, `^r n.aagw,,--z ). , ,-,`_'"'c�,.c 4.:,4`. .,m-^'.-._.1 Y.�,-..-f§,-;,
1 The individual whose name-is listed as a corporate officer or managing member as reported or
listed with the Commission.
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2300002483 0 1
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FORM 103
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Spouses Last Name: .First.Name:
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CITY&STATE CITY&STATE
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FORM 103
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PAGE!
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: — YEAR - ' • — TELEPHONE
. . NAME OF EMPLOYER NAME OF SUPERVISOR '
2.012 2.421. 1)
: ,,, :261,5 4(Lt- ,n4\r_ttliinutisli: _it_ _e, -'‘11,6_. ___,.- IL,. i_tn._ __ .7ti_..16t7i_____7: _____J: 101.1i,--' 11_:.?"___--
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l. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY.
Must be completed by both applicant and spOuse, unless spouse has filed an affidavit of non-
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d. pakicipation.
! Has anyone yktho is a party to this,application, Or their spotisc EVER:been convicted of or plead guilty to any:
charge: Charge means gly charge alleging a felony, miideMeanor,violation of a federal or state law;a;vicilatiCin
of a local law,ordinance or resolution-. List the nature of the charge,where the charge occurred and the year and
-month of conviction or plea, include'traffic,Vjalations. Also list any charges pending at the time of this
'application. If more than one party,please list charges by each individuarsmame. Commission must be notified
Oranyarretts and/orconviCtions that may occur after the date of signing this application.
a YES
If yes,please explain below or attach a separate page.
-Datecif 7- '-'Wheia---- -- Description - ' —------- --- I
Name of Applicant Conviction Convicted t: of Dispaition• I.
(mm/yyyy) (CitY& i Charge ,
.j.•, Stat_01_ '
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2, Have you or your spouse ever been approved or made applicationfor a liquor license in Nebraska or any,
other state?
...„
DYES
IF YES, list the name of the premise(s)
3, Do you, as a manager, qualify under Nebraska Liquor Control Act (1,$•i;4'.olk)l, and do you intend to
supervise,in person,the management Of the business?
'AYES ONO
FORM 103
REV 12/8/2022
PAdE.3
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• 4,, List the alcohol related training and/or experience(when and where)of the person making application:: •
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:::, ••• Applicant Name . Date
1 Name of program(attach copy of course completion!i , (mm/YYYY) • -
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1 *For list of NLCC Certified Training Program. -s see.tio' infiit . • —
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Applicant Name/Job Title ...Date of `,Name_&Location of Business:
', , .-------..— .-- —_ ---:',-Employment!,ii ___..• _ ,,,_. ____.- ._ ,_,_._ i
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5. :it-100.0u enclosed Form 147 regarding fingerprints? •
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YES° ..0.--op •
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FOR4'103
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PAGE-.4
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TERsON-Auct , N74-0
SIGNATURE PAGE PAGE-PLEASE-REM)CAREFULLY —
The undersigned applicant(s) hereby consent(s)to an investigation of his/her background and release,present and ilitUre
records of every kind and description including police records, tax records (State and Federal), and bank or lending
institution records, and said applicant(s) and spouse(s) waive(s) any right Or causes of action:that'said applicant(s)Of
spouse(s)may have against the Nebraska Liquor Control Commission,the Nebraska Side Patrol,and any other
disclosing or"releasing said information. Any documents or records for the:proposed business,:or for,bny,paitner.or
stockholder that arc needed in furtherance of the application investigation of any other iriVestigitiOn:thall be:supplied:
immediately upon demand to the Nebraska Liquor Control Commission or the Nebraska State Patrol The:Cade-1%4
.'..triftletStilitil and tickritrivledgetiat'any4icenseiisucelip sedtn;tliciiiifarrnatinnlybniltAir
comarnedhercun inaccuraievr3traudatifi,
Applicant Notification and Record Challenge: Yourlingerprinis will be used to check the ctitninaihistiny.ovcords of the
FBI. You have the opportunity to complete or challenge the accuracy of the information contained in FBI identification
record. The procedures for obtaining a change,correction;or updating an FBI 'identification record are set forth iaTitle
28. CFR,.16.34.
Must be signed by applicant and spouse.
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Signature Of APPLICANT —
Signature of SPOUSE
S.r-W1411.
- - - -- Printed Name-Of APPLICANTT- "
Printed Name of SPOUSE
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FORM 103
REV 12/8/2022
PAGE 5
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PRIVACY ACT STATEMENT/
SUBMISSION OF FINGERPRINTS/
PAYMENT OF FEES TOINISP-CID
„.
NEBRASKA LIQUOR:CONTROL COMMISSION .
391 CENTENNIAL MALL SOUTH i
•PCI BOX 95046 OaioVraii4fri,f-4-4- - !''
LINCOLN, NE 68509-5046 I li
;. 1112"0:4 ZYrfOrrotrO.ilicil*VitgaYitV% ;1 4
PHONE:(402)471-2571
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FAX:(402)471-2814
We?site: WWV.Iye.rie,l)N4a.,tio, .
THIS'FORMilS REOUIRED,TOZESI4NED_BYEACHTERSONZEING-FiNdEltfillkitti!I
DIRECTIONS FOR AND FEE PAYMENTS:,
i. FAILURE TO PILE FINGEMPRINT_cARDS:ANDWVIMERE01.111(ED,FleTblilt:
JSIEBRASICkSTATETATROL-VILLt/ELO-THEISMIANCE4PYOUR.V4000WIACENSt:
Fee 05 ;w-inof S45:2'5 per-Per-sOn MUST lie Mide.DIRECTLY-6the-Nebraska State Patrol;
It is recommended to make payment through the NSP PayPort online.system ittAkiii-Qiii-dthqgoinsp
Or a check made payable to NSP can be mailed directly to the following address;
***Please indicate on your payment who the payment is for(the name of the person being
fingerprinted)and the payment is for a Ligyor License***
The Nebraska State Patrol—CID DiVision
• 4600 Innovation Drive
[ Lincoln,NE 68521 -
•_: Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP--CID
Applicant(s) will not have cards to Include with license application.
, ••• Fingerprints taken at local law enforcement offices may be released to the applicants;
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1; • Fingerprint cards should be submitted with the application..
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Applicant Notification and Record challenge: Your fingerplmS will be Used to check(lie criMinal lliStot:V.
r
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in the FBI identification record. The procedures for obtaining a change, correction, or updating
1, a FBI identification,record are set forth in Title 28, CFR, 16.34.
r,
"**Please Submit this form with your completed application to(he Liquor Control Commission***
, • 7 •,- .
Trade Name #550 : :,,,, __ _
— '' • 4 il'-Nie'9' kw's' .'111
Name ofPiiii: - : ., - ,,, ._.„. _, __..!._- ___ :: __..7 - - _., -Date of:Wegt
lliaiiiiii
Last 4 SSN ____ .,, __ ----
Date fingerprints wire taken -:_li_.''' -2.D0: . ,-
Location where fingerprints were taken siait-ut_. ,...:5*_i -:,
How was payment made to NSP?
DNSP PAYPORT WASH OCHECK SENT TO NSP CK# _
My fingerprints are already on file with the commission—fingerprints completed for a previous
application 'es,tlf:''' 'years ago? YES 0
SIGNATURE RE U1RED OF PERSON ISEINg.-FINGER-PRINTED ---
:FORmi47:
REV:1UNE 2021
4/5/23,2:36 PM Enterprise Mail-MANAGERS APPLICATION FOR OMAHA CITY COUNCIL HRG-GPM MIDWEST 18
Gmall Carman Johnson (CCIk) <carman.johnson@cityofomaha.org>
MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HRG -
GPM MIDWEST 18
1 message
Carman Johnson (CCIk) . Wed, Apr 5, 2023 at 2:30
<Carman.Johnson@cityofomaha.org> PM
To: LICENSING@gpminvestments.com, "ashleysmith6611 @gmail.com"
<ashleysmith6611 @gmail.com>
Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing
(CCIk)" <kimberly.pulliam@cityofomaha.org>
Good afternoon
RE: GPM MIDWEST 18, LLC
The Omaha City Clerk's Office has received the Manager's application from the
Nebraska Liquor Control Commission. The Omaha City Council will hold a public
hearing on this request on Tuesday, MAY 2, 2023. City Council meetings start at
2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County
Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative
is required to attend the meeting.
I ALSO NEED THE DATE OF BIRTH FOR ASHLEY N SMITH. PLEASE SEND ME
THIS INFORMATION AS SOON AS POSSIBLE.
Please notify me if you have any questions.
Thanks
Carman Johnson
Liquor Clerk
City of Omaha/City Clerk
1819 Farnam Street
Suite LC-1
Omaha, NE 68183
402-444-5324
402-444-5263 fax
https://mail.google.com/mail/u/0/?ik=cd387c45eb&view=pt&search=all&permthid=thread-a:r2466229043256736145%7Cmsg-a:r-89103002349768549... 1/2