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RES 2018-0465 - Walmart Market 4138 appoints Bryan M Hardy manager of class D liq lic loc • E-MAILED TO NLCC 5`7,- {{ l � ! [J o4�vKsst��,�o C1 l� � �� _ STATE OF NEBRASKA -" - "r A'{x Pete Ricketts . , „ NEBRASKA LIQUOR CONTROL COMMISSION GL �•'�°� "'' 20i81',i 23 P,i 3: 58 Hobert B.Rupe 'PC a•:-;�;;.. j Governor �, •�.: �i;, e, �J •� Executive Director ' 301 Centennial Mall South,5a Floor CITY C 1 T • P.O.Box 95046 Lincoln,Nebraska 68509-5046 0 1 i S ro, tV'..'t,d S K ii. 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: BRYAN M HARDY Licensee Name: WALMART INC Licensee Trade Name: WALMART 4138 M 4+/LI( License Number: D-102334 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. APPROVED • NO LOCAL RECOMMENDATION DENIED COMMENTS (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES): 4t. 70\.2 jitt6 (A)- .) s 620) • Clerk Signature: Date: 5/6/I r • Janice M.Wiebusch Robert Batt 11 II I II II II III III II Commissioner • Chairman An Equal Opportunity Employer 1800005426 Apr 20 2818 10:50:24 CDT FROM: F2M/88361416554 M5G# 1729016716-007-1 PAGE 884 OF 021 MANAGER APPLICATION orriceUsc `� INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION rt:^,� ,y ��,� 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 FAX:(402)471-2814 CONTROL COMMISSION Website:N•WW.Icc.nebraska:gov MUST BE: ✓ Citizen of the United States. Include cony of US birth certificate, naturalization paper or current US passnort ✓ Nebraska resident. Include cony of voter reIstration card or print out document frqm Secretary of State website ✓ Fingerprinted. See thrill 147 for further information,read form carefully to avoid delays in processing.this form MUST be included with your application ✓ 21 years of age or older r . t fs: v < i P�. n�ry Name of CorporationfLLC: Y On St t 1/,C t �kj:.TJf: f' `r. "� -.fA � 'M1�-+ �.=j 5 ,}� '.`� � 1.� 'iR�`�i 1 x'lE°�p�� 3 '`, V.I'fir ri ,sCa ff -,t7 Aiq�-y;., .d 1, w.��'�1 .Nt ,.at.,..Xi l ,�.v'� Liquor License Number: FOR \-A Class Type D tiremapphcauim leave blank) Premise Trade Name/DBA:i V a1Moixt Premise Street Address: 92\0! 1(/ 11 , ► 0 1 ‘41/ City: ‘COat 1 Oki County:toog\as Zip Codek.Q It L Premise Phone NumberOM/ Uti IN✓6 Premise Email address:UAW\\ ` ` tk\ mi)1XYL•(.0 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. \1. a C .�� Q , 1 w6a aX OI J J hn. i tit (Faxed signatures are acceptable) Form i U3 Rev Jan 1018 ()age 2 ore'. Apr 20 2010 10:51:00 CDT FROM: F211/88361416554 MSG11 1729816716-887-1 . PAGE 006 OF 021 Last Name: 14 at'(4\ First Name: ty('‘i u M I:11 Home Address: LI9t \. a?C 1'\ City: L I v\i.Q 1 Yl County: Le nt r,S-1-er Zip Code: (0%5 Z. Home Phone Number: LIOZ -(3 I - 7 b� Driver's License Number&State: F 1J e..braS1{o. Social Security Number: Date Of Birth: _ Place Of Birth: No r nrc. j�C g1ZAS14.-A Email address: 43M 1-1Al2D't ci P 14OTA-1 L • Coll l ❑ YES ]NO ; 7 Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number& State: Date or Birth: Place Of Birth: • .. ,.. %I c Y� „ • CITY&STATE YEAR YEAR CITY&STATE YEAR YEAR FROM TO FROM TO L.nc aln UL- h`t}c• f 1oS" Zo,� Form 103 R<v Jan 2018 Pam 3 orb Apr 2B 2818 10:51:35 CDT FROM: F2M/80361416554 MSGU 1729816716—BB7-1 PAGE 008 OF 821 , ( .�i i tit 1�O) f e YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER /VA 1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse, unless spouse has tiled an affidavit of non- participation. Has anyone,who is a party to this application,or their spouse,:EVR been convicted of or plead guilty to any charge. Charge means a y 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,tilts° etrt%..t.-yg' 1Ch!, 5. 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. fn YES ❑ 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&State) Charge yF ❑ it„}t,ek. f,e,,.4.1'..1 )-14.1(d`( �!yt+t 'Sv - Lncil tilit }ili .i• 'ttf'ti+•.i1 ►.i4• 1y�t (( f t t�'u. �t7Ut. ‘At,rl1.! 2O0" (.�nt•rint1 14.::1 1-ovskf.t,rrwrr� 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYES j2NO IF YES, list the name of the premise(s): 3. Do you,as a manager, qualify under Nebraska Liquor Control Act (8,53-13I.01)and do you intend to supervise,in person,the management of the business? ©YES ONO Form 103 Rc-Jan 2018 Pogo aof6 Apr 20 2818 10:52:01 CDT FROM: FZM/88361416554 MSG! 1729816716-887-1 PAGE 018 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 Cenificate: • Applicant Name . Date Name of program(attach copy of course completion certificate) (mm/YyyY) '"For list of NLCC Ccnified Training Programs see training Experience: Applicant Name/Job Title Date of Name&Location of Business: Employment: (37 . u"d, Ahyt /4,.1„ I2111 tut; t.�al,��, c,,...:.t,.., tJ• 5. Have you enclosed form 147 regarding fingerprints? • DYES ,gjN4 • Form 103 Rev Jan 2018 Page 5 of 6 Apr 28 2010 10:53:33 CDT FROM: F2M/013361416554 MSGI$ 1729816716-887-1 PAGE 016 OF 021 SumTotal Page 1 of 1 RECEIVE:0 pizz g,g07e—A!."E az eT a r da`i Yw r o;s:ilY*' Fonzf' `GCS .n nx" �'.�5?w.i.,,.is-,wo.—vr am:•m nszn.. x .�,a.,.... -a-m"'T�d�.:s( d "r°t;., 6'z rg r I C O ?o1Ib.1 t�i V.U�e,a 6VEBRAS6;p LIC " . k CONT El ROL (.OVA !. !ON C a . ark :,- : pi „,,,, Certificate of Completion This is to certify completion ' of Alcohol Sales Training 1. BRYAN HARDY 7/19/2017 :4 Associate Date ft, A Z S: II t is k' z r (5%' y4 [tA ;.3y ..b 44 -,....,.. ...;.a..: http://glms.wal-mart.com/gams/app/management/LM5 ActReports.aspx?Acrid=28326&tJ... 4/19/2018 Apr 28 2818 18:52:18 CDT FROM: FZM/1E361416554 MSGIt 1729816716-887-1 PAGE 812 OF 821 4- 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 1;53-I 3 1.01 1 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 PG I ide fication record are set forth in Tide 28, CFR, 16.34. • ignaturc o anager Applicant Signature of Spouse • • ACKNOWLEDGEMENT State of Nebraska County of The foregoing instrument was acknowledged before me this • 2,0/ by 3 4., ( date NAME OF PERSON DEL ACKNOWLEDGED 11 Affix Scal XV&NAi*state a. Et 9. • tary hubli signature utvivaitEi tiyri5ai.n.i:ia+D.c 3,2020' 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 103 Rcv tan 2018 Page 6 or6 flpr ZH Za18 IA:54:ZH CDT FROM: FZM/H8361416554 MSGII 1729016716-H PAGE HZH OF H21 ECE /F SUBMISSION OF FINGERPRINTS/ h i;' 2 0 20i5 PAYMENT OF FEES TO NSP—CID `={�` Rr-s'` ts' NEBRASKA LIQUOR NEBRASKA LIQUOR CONTROL COMMISSION CONTROL COMMISSION CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 Office Use Only PHONE: (402)471-2571 FAX: (402)471-2814 11 Website: 'www.lcc.nebraska.gov Class: license#: 1 /1221.11 Applicant Name: Y 0, l(1 (Corporation,LLC,Partnership or Individual) Trade Name:\N�1 (t (Doing Business As) Mck-1,11- ciN97, C OMO '��a\-mar- .c.,c,rn Phone Number Contact E-mail�d2rress 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 LIOUOR 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 PayPdrt 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 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 213 2018 18:54:40 CDT FROM: FZM/88361416554 MSG# 1729016716-087-1 PAGE 821 OF 021 Q2Y Lkf \\aid -t __`. .. ._-l. Name Date of Birth: Last 4 SSN.: Date fingerprints were taken: tA --1k� Location where fingerprints were taken: ' ,k I How was payment made to NSP? 4:8(P PAYPORT OCASH ❑CHECK SENT TO NSF 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 OCHECK 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 4. Name: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSF 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 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): Y L UVW (V) Title:P5t. Cj,Y, • Signature: .�' Date: C.A,a 1 • FORM 147 REV JAN 2018 PAGE 2 City of Omaha, Nebraska 1819 Farnam —Suite LC 1 zTar gt Omaha, Nebraska 68183-0112 Q r '���,,;r,0, Elizabeth Butler 402 444-5550 '` "'" les City Clerk FAX (402) 444-5263 0 TFD FEBR ' May 1, 2018 Walmart, Inc. Application to appoint Bryan M. Hardy Dba"Walmart Market 4138" manager of your present Class "D" Liquor 13105 Birch Drive License location Omaha,NE 68164 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 �oMAHA, NF city ofOmaha, Webras&a � 11Wit 1819 Farnam —Suite LC 1 z wSr _� '� Omaha, Nebraska 681 83-01 1 2 � r1 `^y�'0i�� Elizabeth Butler (402) 444-5550 �,o = - �_ r ti- City Clerk FAX (402) 444-5263 9 '3 rFo FEBR1uA May 1, 2018 • Bryan D. Hardy Application to be appointed manager of the present 4931 North 20th Class"D"Liquor License location for Walmart, Inc., Lincoln,NE 68521 dba"Walmart Market 4138", 13105 Birch Drive, 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 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