RES 2018-0460 - Appoint Roger L Radloff manager of Walmart E-MAILED TO NLCC _ __ TLY
�- o.-� ! ( L. , �. ` STATE OF NEBRASKA
~ '`c NEBRASKA LIQUOR CONTROL COMMISSION
�� - �..P� Pete Ricketts ��,� � Hobert B. Rope
�,�=- a 1.y, n ;t : 58
a• Governor APR 3 (�,
x, .1� T. , Executive Director
'�, ii 301 Centennial Mall South,5th Floor
a�«,.,,� P.O.Box 95046
G i-L Lincoln,Nebraska 68509-5046
C H A'.ti , iv, v(A c�{ A Phone(402)471-2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
Web address http://www.lcc.nebraska.gov/
. 4/23/2018
•
To: • CITY CLERK OF OMAHA
. Email: CARMAN.JOHNSON@CITYOFOMAHA.ORG
Manager Name: . ROGER L RADLOFF
Licensee Name: WALMART INC
Licensee Trade Name: WALMART 1637
License Number: D-62657 •
Due Date: Thursday, June 07, 2018
I have attached a copy of a new manager application that was submitted to the Nebraska Liquor •
Control Commission. Please complete the following information below to indicate your
recommendation. Send back to TRACY at tracy.burmeister@nebraska.gov or fax to 402-471-
2814. If you have questions concerning this matter, please contact our office at 402-471-2572.
X APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES):
oqP 2es LIVID MA. - lsl g0
•
Clerk Signature: J •
•
—
Date: 5i)(,I1 r .
Janice M. Wiebusch Robert Batt
,>,,,,,,i.,.,i„ c;,.,r,,,;.;;,
t: 1800005424
Apr 19 281B 14:82:44 CDT FROM: FaM/89361416554 MSGIt 1431322648-887-1 PAGE 882 OF 021
MANAGER APPLICATION olticcuse
INSERT-FORM 3c RECEIVES}
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH APR C 0 2018
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 NEBRASKA LIQUOR
FAX:(402)471-2814 1�� 1�5�0�
Websile:www..lec.nebra_aka.gov CONTROL O
MUST BE:
V Citizen of the United States. Include cony of US birth certificate,naturalization paper or current US
passport
✓ Nebraska resident. Include copy of voter registration card or print out document from Secretary of
State:website
✓ Fingerprinted. See form 147 for further information,read form carefully to avoid delays in
processing,this form MUST be included with your application
✓ 2I years of age or older �'
arg�j yam- SaT uyf 5dk' � oF'�'e' ,, uT�ik d'l��y�.���"'r+�'�"¢h ��e .����.�� -'��'
i I1Qt dill` ys�±�(a��.tny_�: .c,:4411 �.. .*,7.' "f"' ith€ ...,�,���`„ya;. ) f. ;rn'� ".'r.A:.t��'a.?!' i S':�., s.
Name of Corporation/LLC:Y Ok l 1Q 't ,\V•
l� i{y�il•`t : �`r ...:... :e'. 0 f Y t Xr„ 'M 's"�IANOhFE
Liquor License Number: (..9, J i Class Type t) frnew'cpplicatinn leave blank)
Premise Trade Name/DBA: MOM M C \L-1v 1 -"J1
Premise Street Address:C 2?��� 1 V 1.Q.,..tt-
City: OMiAV(k County: '0 t(A.S Zip Codc:�0 l3U
Premise Phone Number:a/ W V r "19"t t-A
Premise Email address: ,V (\ 11c Y V U1\-11 O 1 t • UV)
)
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. To see authorized officers or members search your.
license information here.
J// �' .. -as r i }. -_ .� "��f i".' §s fi•` ii
f- , ' keg $ ta]r ,, �; !I . ` .
(Faxed sigttatures arc acceptable)
Farm 103
Rev Jan 2018
Page 2 of
Apr 19 2818 14:03:15 CDT FROM: FZM/88361416554 MSGIt 1431322648-887-1 PAGE 884 OF 821
r �
Wilia liti`"15a9J!irlitO s&tom'► irera elgiv' b E``ASEfOli NrGLEARL Y ,, ...
Last Name: 1c2-4o1.QFi First Name: 4 MI:
Home Address: \ 'D3 �O UV-- C,t Q,,CtA. / p
City: U IAAIA f County: E Zip Code: g I3.5
Home Phone Number: LID)--51,1 I- 2-3
Driver's License Number&State: • E AJ S
Social Security Number: - . - - —-
t _ ,
Date Of Bulb: , ' . Place Of Birth: T V11'&)a E (D wA
Email address: G R.E.-AT ,a,O y @ G No1L • Co•A
bay° `el'i r.{i�"�•{►r �'if :io i� ��h'7r` '�M T'.?r'i e:it i�i�i �s r �• 15S�. X. a war ir-y7:tFsm
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g YES ❑NO
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e i�`. ; ,< .� �r , ..xc a•r�:I5',.e. ' � 1 i4;T„y.w.: ax.t '_ .i ?.. 'Fm'<�. '�a�^.t.,^L e"'�' -
Spouses Last Name: 12-AD LO First Name: CA'4114 l A MI:
Social Security Number: _ _ -
n
Driver's License Number&State:
Date Of Birth: - - Place Of Birth: 1 t FFl"t C)tk to
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d::<...xc;y< .�G 6: �dyi t,t+y etY ZirTk`' ��V iz „`"�? '. .. .a a
CITY&STATE YEAR CITY&STATE YEAR YEAR
FROM TO FROM TO
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Form 103
Rcv Jan 2018
Pagc 3 of 6
Apr 19 2818 14:03:51 CDT FROM: FaM/80361416554 MSG1t 1431322648-0V-1 PAGE 006 OF 021
FROM A TO NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONUMBENE
2otl g-ot% iota. ton.-r NEts Nt~vso,a qba- 49a_ C13414
011 a'Ota- Y tIL SNOB tft' s I-1413-51'6a'
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,gmbeen 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,Rit~rzaVritiii. Also list any charges pending at the time of this application. If more than
one party, please list charges by each individual's name, Commission must be notified of any arrests and/or
convictions that may occur after the date of signing this application.
YES ❑ NO
rf yes,please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
(mm/vyyy) (City&State) Charge �
t)C^n Ulr6t'�' O6 f o 11 f�eh octt-11 5( —1 AtA b kktG.Er (Ft'`l fc
Ro R - QQtA 0 6 I 9-o 15 N— A Sec4zo It3 --,—t .er ,"�
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
DYES (MNO
IF YES,list the name of the premise(s):
3. Do you,as a manager,qualify under Nebraska Liquor Control Act ($53-131.011 and do you intend to
supervise,in person,the management of the business?
YES ENO
Form l03
Rcv Jan 2018
Pagc4of6
Apr 19 2818 14:84:17 CDT FROM: FRM/88361416554 MSGtt 1431322648-887-1 PAGE 008 OF 021
•
•
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NLCC Training Certificate.Issued: Name on Certificate:
Date {
Applicant Name ( yYYy) Name of program(attach copy of course completion certificate)
RDt�6"- Q—AMAO O'/X1I1 10At.N11tiT At.tDtiDL SAt,s IR,AIN%' '
*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
Q.Aot,otff/PSStsvast NpA ;OR'AO W an�eu,K 0MbHA Pi(
tote"-tpot-oGt+r .9it 140/AA-% a'�Utt-�etp- tt-- s•1o( Qt\Aw, /4E.
46 -QOO.oJf t 45tSSb.rc 11‘01*14I ;1303-?ot1 WA 4Movvr t)top tao "JE
S. Have you enclosed form 147 regarding fingerprints?
OYES ONO
Form 103
Rev Jan 201R
Pap 5 of 6
Apr 19 2818 14:05:34 CDT FROM: F2M/88361416554 MSG1$ 1431322648-007-1 PAGE 816 OF 821
GLMS Page 1 of I
RECE8VED
APR 2 0 `018
NEEBRASKA L i0UOE
Walmart s CONTROL COMMISSION
Certificate of Completion
This rs to ceptify completion
of
Alcohol Sales Training
ROGER RADLOFF 6/27/2017
Associate Date
Intp://glms.wal-mart.com/glens/app/management/LMS—Aetlteports.aspx?Actld-.,28326&.iscrMode=0&Mo... 4/17/2018
Apr 19 2018 14:04:33 CDT FROM: 12M/88361416554 HSEU 1431322648-007-1 PAGE 010 OF 021
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 bas
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 453-131.01)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,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
contained in FBI identification record The procedures for obtaining a change. correction, or updating an
FBI identi:cation record are set forth in Title 28, CFR, 16.34.
Clitd
Signature of Manager Applicant Signature of S ouse
ACKNOWLEDGEMENT
State of Nebraska�
County of ?�1 it A "1--, The foregoing instrument was acknowledged before me this
-R9c-' l 1� l 2 by S ���j�n k±urlawi V ,1
due NAME OF PERSON BEING ACKNOWLEDGE
e... ' Affix Seal
otrasicy
Notary Public signature- G EBONNOTY R.st�+-State o
... My Comm.Etp.,Nirr 10.2021
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.
ra,m 103
Rev Jan 2018
Page 6 of 6
Apr 19 2018 14:05:00 CDT FROM: F2M/88361416554 MSG11 1431322640-007-1 PAGE 012 OF 021
•
SPOUSAL AFFIDAVIT OF omee Use 4
NON PARTICIPATION INSERT EC :_'EIVE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH APR A ? tj
PO BOX 95046
LINCOLN.NE 68509.5046
PHONE:(402)471.2571
•
PAX:(402)4714814 NEBRASKA LIQUOR;
Websitc: www.lccmcbraska.eov
CON t HOL COM:•.IpSSION
I�' '1 l 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 053-125(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.
I acknowledge that I am the applicant of the non-participating spouse of the individual signing below. I
understand that my spouse and I are responsible for compliance with the conditions set out above. If, it is
determined that my spouse has violated(§53-125(13))the commission may cancel or.revoke the liquor license.
- CA di 71
sr
Signature of NON-P X IPATING SPOUSE Signature of APPLICANT
(Ott" P-00*-- A riotPrint NCidnAAU.0e Print Name
State of Nebraska,County ofTT)OL Q State of Nebraska,County . t.A S,
The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me
this (\cc'l \ ler ?(alb (date) this Apc 1 1 1 C e�) 2Q 1 8 (date)
by ( 0-1-h‘a tad toff by tCoo s— CA.C11t C"
Name of person acknowledged Na de of person acknowledged
(Individual signing document) (Individual signing document)
7 ---.- -------------
/r otary ublic Signature No Public Signature •
XNERAL NOTARY•State of NebcaSkrl NOTARf-Stated Nebraska
EBONY R.SMOAKAfi scat ^ GENERAL
R.SOAR'Sea
lay Cotttltt.l ip.July 10.2021J t . My Comm.Esp.July 10,2021
In compliance with the ADA.this spouse!amdavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 116
REV NOV 2016
Page 1 1
Apr 19 2018 14:06:33 CDT FROM: F2M/88361416554 MSGU 1431322648-007-1 PAGE OM OF H21
SUBMISSION OF'FINGERPRINTS / RECEIVED
PAYMENT OF FEES TO NSP-CID :74"11:f` FF.Ct:°°'f`
APR 2 0 2018
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH NEBRASKA LIQUOR
PO BOX 95046
LINCOLN,NE 68509-5046 CONTROL COMMISSION
PHONE: (402)471-2571 Office Use Only
FAX:(402)471-2814
A)
Website: www.lce.nebraska.gov Class: License#: �Q? Lo_51
Applicant Name: ` li t la It 1NV .
(Corporation,LLC,Partnership or Individual)
Trade Name: V V 1,`*‘00A krbl
(Doing Business As)
u\°1-111'GIC12 m)t191i L WcA\-ma.vt• c o lm
Phone Number Contact E-mail Ac2ffess
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED PROCESSING FEE TO
THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR
LICENSE.
• See Application'Requirement Guide for listing of Fingerprint Requirements found on our website under'
"Licensing"tab in"Applicant Guidlines".
• DO NOT send fee payments to the NLCC—fees MUST be paid directly to NSP.
• Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol;
It is recommended to make payment through the NSP PayPort online system at www.ne.gov/Qo/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 License***
The Nebraska State Patrol—CID Division
3800 NW 12th Street
Lincoln,NE 68521 •
• Fingerprints taken at NSP 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 will be released to the applicants;
Fingerprint cards should be submitted with the application.
Please complete Information on the following pages for EACH person fingerprinted.
FORM 147
REV JAN 2018
PAGE 1
•
Apr 19 2810 14:86:58 CDT FROM: F2M/88361416554 MSGI1 1431322648-887-1 PAGE 821 OF 821
1. Name:U ` X ,611 Date of Birth. = Last 4 SSN:
Date fingerprints were taken: ` \'b Location where fingerprints were taken:MA poop►u
How was payment made to NSP? SP PAYPORT ❑CASH ❑CHECK SENT TO NSP Ck#
My fingerprints are already on file with the commission-fingerprints completed for a previous
application less than 2 years ago YES 0
2. Name: Date of Birth: Last 4 SSN:
Date fingerprints were taken: Location where fingerprints were taken:
How was payment made to NSP? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP Ck#
My fingerprints are already on file with the commission-fingerprints completed for a previous
application less than 2 years ago YES ❑
3. Name: Date of Birth: Last 4 SSN:
Date fingerprints were taken: Location where fingerprints were taken: •
How was payment made to NSP? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP Ck#
My fingerprints are already on file with the commission-fingerprints completed for a previous
application less than 2 years ago YES ❑
4. Name: Date of Birth: Last 4 SSN:
Date fingerprints were taken: Location where f ngerprints were taken:
How was payment made to NSP? ❑NSP PAYPORT OCASH ❑CHECK SENT TO NSP Ck#
My fingerprints are already on file with the commission-fingerprints completed for a previous
application less than 2 years ago YES 0
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
contained in FBI identification record. The procedures for obtaining a change, correction, or updating a FBI
identification record are set forth in Title 28, CFR, 16.34.
•
I hereby certify that fees of$45.25 per person have been submitted directly to the Nebraska State Patrol—CID
office. The undersigned certifies on behalf of the Corporation,LLC,Partnership or Licensee that it is understood
that a misrepresentation of fact is cause for rejection of this application or suspension,cancellation or revocation of
any license Issued.
Name(Print):MOM /U.'tQV l Xi Title:ka' %is
erAyki
Si nature: l//A`'" Date:
Jig
nature:
147
REV JAN 2018
PAGE 2
°rAAHA, N
City ofOmaha,. Webras&d 4 `v ��
C.) /1111.411M7
1819 Farnam — Suite LC 1 -' ''� , �'
Omaha, Nebraska 68183-0112 in` (4)m.,_
"mow
Elizabeth Butler (402) 444-5550
City Clerk FAX (402) 444-5263 0439 ED E R Age
May 1 2018
Walmart, Inc. Application to appoint Roger L. Radoff
Dba"Walmart 1637" manager of your present Class "D"Liquor
6304 North 99th Street License location
Omaha,NE 68134
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 May 15, 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
City � �
o f Omaha, Nebraska �MAHA,
��,
4.10011Alk"t;
1819 Farnam — Suite LC 1
Omaha, Nebraska 68183-0112 rL /
Elizabeth Butler (402) 444-5550
City Clerk FAX (402) 444-5263
9TFD FEBRU�'
May 1, 2018
Roger L. Radloff Application to be appointed manager of the present
17234 Polk Circle Class"D"Liquor License location for Walmart, Inc.,
Omaha,NE 68135 dba"Walmart 1637", 6304 North 99th Street
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 May 15, 2018 . The City Council
Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic Center,
1819 Famam 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