RES 2018-1071 - Sam's Club #8146 appoints Stacy S Garver manager E�:�ws srtr�,t
E-MAILED TO NLCC
STATE OF NEBRASKA
Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION
1 k 1 Governor
7 Hobert B. Rupe
Executive Director
301 Centennial Mall South,5th Floor
• P.O.Box 95046
Lincoln,Nebraska 68509-5046
OCT 18'1 AF' -- p+39 Phone(402)471-2571
l:ii�F ClerkClerkI�IIp_(�. . .-'tG l Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
web address http://www.lcc.nebraska.gov/
October 16, 2018 •
•
To: CITY CLERK OF Omaha
Email: carman.johnson@cityofomaha.org
Manager Name: Stacy S Garver
Licensee Name: Sam's West Inc
Licensee Trade Name (DBA): Sam's Club 8146
License Number: 086819 .1, •
Date Due: November 'h7, 30, c2o)k 6).
•
I have attached a copy of a new corporate manager application that was submitted to the Nebraska
Liquor Control Commission. Please complete the following information below to indicate your
recommendation. Send back to Kim Frederick at kim.frederick a nebraska.gov or fax to (402) 471-
2814. If you have questions concerning this matter, please contact our office at (402) 471-2573.
X APPROVED
•
NO LOCAL RECOMMENDATION
DENIED •
•
COMMEN S: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES)
3 Z),,s MI
•
Clerk Signature: Lb Date: II Zi Ag
. KMF . '
•
Janice M.Wiebusch Robert Batt Bruce Bailey
Commissioner Chairman Commissioner
An Equal Opportunity limployer
Oct 82 2010 17:24:28 CDT FROM: F2M/88361416554 MSG11 1478443983-887-1 PAGE 883 OF 812
MANAGER APPLICATION Office Use
F
-INSERT-FORM 3c RECEND
' NEBRASKA LIQUOR CONTROL COMMISSION I, 1) 3 •,: ),
301'CENTENNIAL MALL-SOUTH
PO"BOX 95046
• LINCOLN,NE 68509-5046 NEBRAY.:3Vo: 7.C2Licy:
PHONE:(402)471-2571 CONTROL CCirilMiSSION
- FAX:(402)471-2814 •
Website: YWw,lCcflg9V ,
•
MUST BE:
• Citizen of the United States. Include covv-of US birth tertificate.naturalization paver or
current US passport
• V Nebraska resident. Include cony of voter realstration in the State of Nebraska
✓ Fingerprinted. See Form 147 for further information,this form MUST be included with your
application.
- V 21 yeari of age or older
Vs'31it' '`:v6Wc.: Yp::)'.17.,7;: .11V1,1v.p:;,A.t-,N • '
Name of Corporation/LLC AnM r) ji>t
V\I .
„...,
I' ^',^r • „'q ^ , ;,07
krniirikei
Liquor License Number krt I • Class Type t (if new application leave blank)
is% ,
Pi-emise Trade Ntirne/bBA: kM kji V V 111 .
Premise Street Address:\13‘ )0.
City: V1104\11.0k, County:bbti octs zipcode:usn
1 Premise Phone Number:ittld 7A1-1-102t9
Email addtess:OVA V III&T 1 ,Yt DV\A
•
The individual whose name is listed as a corporate officer or managing member as reported on insert
form 3a or 3b or listed with the Commission. Click on this link to see authorized individuals.,
Iittn://www.lcc.ne.govilicense sea rch/licsearch.cei
SIGNATURE REQUIRED BY RPOUTt OFFICER PiTiVitsAditstaKEIVIEBig- R
,-ed signatures are acceptable)
Fenn 103
• lkEV JAN 2015
Page.2 of 6
Oct 02 2018 17:25:11 CDT FRO11: FMM/80361416554 • MSg 1470443903-007-1 PAGE 884 OP 012
t
Manager's information must be completed below PLEASE PRINT CLEARLY
Last Name: Gar voC First Name:v 61 MI'S •
Home Address: i V(Q ZZ S. 2•-I 6 S -11-et::/'' ;
City: bit--7 �' co,inty. Ltd"� lag a 2g
zip coax:
1 Vtg-3(-1q0
Home Phone Number 1 I Z—
Driver's License Number&Stater'"- ' ' - ��`rbrak
Social Security Number. , -- ' --
Date Of Birth: . Place Of Birth: nrtni t\E .
Email address �� b 1 A.t h $ Q. • OnAre you married?If yes,complete spouse's information(Even if a spousal affidavit has been submitted)
VYES ci
NO .4 c s
,
Spouse's Information Spouses Last Name: Bair � �r. First Name: CrCL to MI:L
Social Security Number: _- • 1 — v ,
Driver's License Number&State: tH\le-tralkek_,
~ 1sI 1i
Data Of Birth: _ . • Place Of Binh:_��
APPLICANT&SPOUSE MUST LIST RESIDENCE(S)FOR THE PAST TEN(10)YEARS •
APPLICANT SPOUSE
,---- CITY&STATE FROM r Y�o • CITY&STATE [YEARFROM , YTO
G' rt+-7-tq, l dzrr_44-
_ _
Foam WI
Rev raozo►t
Page 3 of 4
Oct 02 2018 17:25:49 CDT FROM: FZM/88361416554 MSG11 1470443983-087-1 PAGE DOS OF 012
MANAGER'S LAST TWO EMPLOYERS
YEAX
FROM TO
NAME OF EMPLOYER NAME OF SUPERVISOR
1'93 fJ� L4 a/ma . (ne.,. ��. h .,S l) q62.._33OR'�O--
J9?s o
1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY.
Must be completed by both applicant and spouse, unless spouse has filed an affidavit of non-
participation.
Has anyone who is a party to this application,or their spouse,Era,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,include traffic violations. Also list any charges pending at the time of this application. If more than
one party, please list charges by each individuai's name. Commission must be notified of any arrests and/or
convictions that may occur after the date of signing this application.
❑ YES 0/ NO
If yes,please explain below or attach a separate page.
Date of Where Description-
Name of Applicant Conviction Convicted of Disposition
(mm/yyyy) (City it State) Charge
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
OYES NO
IF YES,list the name of the premise(s):
3. Do you.as a manager,qualify under Nebraska Liquor Control Act 053-131.Q11 and do you intend to
supervise,in person,the management of the business?
OYES ONO
Form 103
R�Jan20111
Pogo 4 of 6
Oct 82 2810 17:26:22 CDT FROM: F2M/88361416554 MSG 1478443983-807-1 PAGE 886 OF 012
4. List the alcohol related training and/or experience(when and where)of the person making application.
*MCC Training Certificate Issued: Name on Certificate:
•
Applicant Name (my') Name of program(attach copy of course completion certificate)
-+
'For list of NLCC Certified Training Programs ace training
Experience: _ of
-- t
Applicant Name/Job Title Date ne Name&Location of Business:
Emyloyment:
5. Have you enclosed form J47 regarding fingerprints?
OYES QNO
Fonn 103
Rev ha 201E
Page 5 of 6
Oct 82 2018 17:28:02 CDT FROM: F2M/88361416554 MSG# 1470443983-807-1 PAGE 810 OF 012
111
G5 ' `
Course
ALCOHOL SALES ATI v.,DED
:: ^JJ TRAINING (2.3)
030 Minutes •
Attempt History
STAR f
Alcohol Sales-Is a compliance CBL By the end of this course,you will
understand how to Identify and handle situations involving the sale of
ti . • :.::, ACTIVITIES DETAILS
Notes
Below are the details about this activity including activity user notes and
instructor notes.
, User notes:By the end of this course,you will understand how to identify and
handle situations Involving the sale of alcohol,and applicable register prompts.
•
Additional Information
Below are the additional details about this activity such as facility,location and
so on.
Activity status:Active
Delivery method:eLearning Media:Web Based Training
Code:CBL11324
Training organization:Wal-Mart
Stores,Inc
This activity fulfills the following
• activities:
Alcohol Sales Training
Oct 82 2018 17:27:13 CDT FROM: F2M/B8361416554 MSGII 1470443983-007-1 PAGE 008 OF 012
PERSONAL OATH AND CONSENT OF INVESTIGATION • i
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. LSec_653-131.0J1 Nebraska Liquor Control Act.
i
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.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
cont. ne, tificaiion record. The procedures for obtaining a change, correction, or updating an
.,
FB iden $ion rrd are set forth in Title 28,CFR, 16.34.
ir
goatur•�'' anager Applicant Sig re of Spouse i
•
ACKNOWLEDGEMENT
State of Nebraska
County of
JCl tr ri The foregoing instrument was acknowledged before me this
-.a$-I J t .S�LeY-
daze NAME OF?EASONN BEING ACKNOWLEDGED
MR%Sat=tow.Stitt of tutttu a
Notary Public signature HAWN MORRISON
Comm.Egt jel It 2021
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 to3
Rcv Ian 2018
Pesc6of6
Oct 82 2010 17:26:48 CDT FROM: F2M/88361416554 MSGil 1478443903-007-1 PAGE 087 OF 012
SPOUSAL.AFFIDAVIT OF Wee Use
NON PARTICIPATION INSERT
NEBRASKA.LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO SOX 95046
LINCOLiN.NE 6i509.5046
PHONE:(402)471.2511
FAX;(402)471,2i14
Website:www.Itzwelomka.gov
1.0-ei I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will
not have any interest,directly or indirectly in the operation 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 invoices,represent myself
as the owner or in any way participate in the day to day operations of this business in any capacity. The
penalty� � guideline for violation of this affidavit is cancellation of the liquor license.
•
Art{ I acknowledge that I am the applicant of the non-nsrjcipating spouse of the individual signing below. I
understand that my spouse and I are responsible for compliance with the conditions set out above. It7 it is
determined that my spouse has violated(§53-125(I3))the commi may cancel or revoke the liquor license.
1
Signa -P CIPAT1NQ SPOUSE Si A •
Print Name Print Name
State of Nebraska,County of .f State of Nebraska,County of sure/
,•
The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me
this r -f g /(date) this -?py- (date)
by Ronal a 6,LUN -r- _ by
Name of person acknowledged Name of paean a wiedged
(Individual signing document) (Individual signing document)
Notary Public Signature Notary is Signature
XD/A="h1WAN Q.—OEM
NOTARYAY-St ski
My tam kttj 19.2021 SHE NN MORRISON
In compliance with the ADA.this spousal affidavit anon participation Is available in other formats for persons with disabilities.
A ten day advance period is rammed in wntins to produce the alto:aate Rsmas.
FORM 116
REV NOV 2016
Pagel
Oct 82 2818 17:20:41 CDT FROM: F2M/88361416554 MSGit 1478443983-087-1 PAGE 812 OF 812
PRIVACY ACT STATEMENT/ r , . • • , . -11 a
SUBMISSION OF FINGERPRINTS/
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH .
PO BOX 95046 • .. - .. . .::'! ,:.;,
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 L
FAX:(402)471-28 1 4
Website:www.lcc.nebraska.gov
'HIS tQRM IS REOVIRED TO BE SIGNED BY EACH PERSON BEINOFI iGERPR3l5TED:
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAYTHE RBOUIRED FEE TO THE
NEBRASKA STAT$PATROL,WILL DELAY TUB ISSUANCE QF YOUR LIQUOR LicEjsISE
• Fee payment of$45.25 per person MUST be made DIRECTJA to the Nebraska State Patrol;
It is recommended to make payment through the NSF'PayPort online system at www.ne.gov/go/nsp
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 Liquor Dense***
The Nebraska State Patrol-CID Division
• 3800 NW 12th Street
' Lincoln,NE 68521
• Fingerprints taken at NSF LIVESCAN locations will be forwarded to NSP-CED
Applicant(s)will not have cards to include with license application.
• Fingerprints taken at local law enforcement offices may be released to the applicants;
Fingerprint cords should be submitted with Me application.
Applicant Notification and Record Challenge: Yourfingerprints will be used to check the criminal history
records of Me 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 a
FBI identification record are set forth in TitleTi 28, CFR, 16.34.
Trade Name:�lQl l 1 S 4\ V) ti
Name of Person Bring Fingerprinted:. ,S+Ol f 5 . 00.Y VC,r
Date of Birth: . . _ ,ast 4 SSN:. _ _ Date fingerprints were taken: 10-"' 26 1'
Location where fingerprints were taken: : Ncbr*Si e $fixtr. { 5d7-b-f C j e -Opi .ho
How was payment made to NSP?
kSP PAYPORT OCASH ❑CHECK SENT TO NSP CK# _
fingerprints are alr d file with the commission—fingerprints completed for a previous
application les tha y ago. YES 0
SIGNATURE REQU D ERSON BEING FINGERPRINTED
FORM 147
REV MAY 2018
Cityof Omaha, SAle bras a 4.o�,\BAH 1
1819 Farnam —Suite LC 1 z "
Omaha, Nebraska 681 83-01 1 2 ' ',,r4t ilhsW
Elizabeth Butler (402) 444-5550 �'�` x ry.
City Clerk FAX (402) 444-5263 0�9—' 4�
4 D FEBR3P
November 6, 2018
Sam's West, Inc. Application to appoint Stacy S. Garver
Dba"Sam's Club#8146" manager of your present Class"C"Liquor
13030 "L" Street License location
Omaha,NE 68137
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 November 20, 2018 . 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 or his/her representative 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,
Elizabeth Butler
City Clerk
EB:clj
AHA,
City ofOmaha, J'lebraskg �4ir/�,p9s
1819 Farnam — Suite LC 1 z ' .., i .'c t=r' I
Omaha, Nebraska 681 83-01 1 2
Elizabeth Butler (402) 444-5550 t`- — _ ti
City Clerk FAX (402) 444-5263
TFD FEBR�P
November 6, 2018
Stacy S. Garver Application to be appointed manager of the present
10622 South 210th Street Class"C"Liquor License location for. Sam's West,
Gretna,NE 68028 Inc., dba"Sam's Club#8146", 13030 "L" Street
Omaha,NE
Dear Liquor License Manager Applicant:
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 November 20, 2018 . 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 or his/her representative 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,
Elizabeth Butler
City Clerk
EB:clj