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RES 2016-0906 - Appoint Tahmina Samiev manager of Mega Saver E-MAILED TO NLCC , I. / 1...... i 47 .4•••• li*'1, STATE OF NEBRASKA Ilk Pete Ricketts 2n1",-1 t ,.., NEBRAKA S LIQUOR CONTROL COMMISSION ,,4, - •Ay, Governor Hobert ES.Rupe 'Ir' - - Exectinve Drrector , . 301 Centennial Mall South,5th Floor MANAGERRKOMMENDATION RO Box 95046 Lincoln,Nebraska 68509-5046 Phone(402)471-2571 DATE: May 18th,2016 Fax(402)471-2814 or(402)471-2374 IRS USER 800 833-7352(TTY) web address.http://www(cc ne.gov/ TO: Omaha City Clerk E-MAIL: carman.iohnsonPcitvofornaha.org MANAGER: Tahmina Samieva LICENSEE: TFL, Inc. dba Mega Saver 2014 L Street Omaha LICENSE#: D-079482 DUE DATE: July 5,2016 Attached is a copy of a new manager application submitted to Nebraska Liquor Control Commission. Please complete the following to submit your recommendation. Send back to Tracy Burmeister at tracv.burmeisterPnebraska.Rov or fax to(402)471-2814,with questions call(402)471-2572. XAPPROVED NO LOCAL RECOMMENDATION DENIED COMMENTS: (7. e...to ht-206 ,,, ssci & --.0 9 1-I 4e> (may attach minutes and/or additional notes) CLERKS SIGNATURE: DATE: 40.1,a .247. Il I Janice M.Wiebuach Robed Batt I 1 I 600II 1 I 1 11 0 Commissioner Chairman An Equal Opportunity Employer MANAGER APPLICATION Office Use INSERT- FORM3c = �. NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX:(402)471-2814 website:www,lcc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: • Complete all sections of the application. Be sure it is signed by a member or corporate officers corporate officer or member must be an individual on file with the Liquor Control Commission • Fingerprints are required. See form 147 for further information,read form carefully to avoid delays in processing, this form MUST be included with your application. • Provide a copy of one of the following: US birth certificate,naturalization papers or current US passport(even if you have provided this before) • Be a registered voter in the State of Nebraska, include a copy of voter card or print document from Secretary of State website with application Spouse who will not participate in the business, spouse must: • Complete the Spo•asal Affidavit of Non Participation Insert(must be notarized). The non- participating spouse completes the top half; the manager completes the bottom half. Be sure to complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business,the spouse must: • Sign the application • Fingerprints are required. See form 147 for further information, read form carefully to avoid delays in processing,this form MUST be included with your application. • Provide a copy of one of the following: birth certificate, naturalization papers or current US passport (even if you have provided this before) • Be a registered voter in the state of Nebraska, include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required Form 103 REV MAR 2016 Page 2 of MANAGER APPLICATION Office Use INSERT-FORM 3c 'N i T;rvw NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX:(402)47I-2814 Website: www.lcc.nebraska.gov MUST BE: ✓ Citizen of the United States. Include copy 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 ✓ 21 years of age or older a7�san?m�''�« mod' 5§' I� .s, �'" •w,HL.'�".`i?`� �` �.�#_. � a` 'r _ w'�` x>:, �+"a .' ✓; ar;.'4P .q:d#+t...n.s ,. kF �Yg. .,. ,., Name of Corp©ration1LLC:TFL, Inc. (S.o.S.# 10045933) 716"a:` w.a. Ct�'; a.u, t '£v" ,2t � $ xj5` _ y1.J` r .. }?.? �...$ �x„v: .�G /�: .. � Liquor License Number: p - ©4q t1 8 Z Class Type /,J (if new application leave blank) Premise Tru de Name/DBA: eaci S&v e r Premise Street Address: �` 0 14 e-eA City: Om AAA County: bot3 I4.s Zip Code: 64'I O9 Premise Phone Number: (if oi) 4,3.2 - 53 Premise Email address: 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. 1LA-t �. SIGNATURE REQUIRED BY CORPORATE OFFICER I MANAGING MEMBER (Faxed signatures are acceptable) Form 103 REV MAR 2016 Page 2 of 6 Manager's information must be completed below PLEASE PRINT CLEARLY Last Name: .5 ova First Name: Tek h ;IAA Home Address: 136 1 0 Preet City: a*4-44 County: Do"-3 leTS Zip Code: Se:PIS-4 Home Phone Number: (11001) 4•0 6- e 42-5- Driver's License Number& State: lv E Social Security Number: - Date Of Birth: Place Of Birth: /eti Sirt-41 Email address: 44-hm4t4.4 _ At4n4evat 6i) katmAtt,/ I. coo/ 5ArfeY644:r.e1161771:17 iffitifrz 'CVO Nfitkii1461.:44Y1 !Zi YES EJ NO OMISVail :f4EF -#42.Atr 4A:k Spouses Last Name: Set-ov;t V First Name: Multi fr h of MI: Social Security Number: Driver's License Number& State: _ /V E- . Date Of Birth: Place Of Birth: T4 J 01" 5'* tr.e,';.:4LIV41),IP N(5:4 tiF ti0,11 cf7,14.1:1 1'014 Wirt 11 "'14 ltV YEAR YEAR CITY & STATE YEAR CITY& STATE YEAR FROM TO FROM TO OhlaA4 .(coo 0 .0 1 6 Osii-AA tv-e- a 000 4014 Form 103 REV MAR 2016 Page 3 of 6 .. a MANAGER'S'LAST TWO EMPLOYERS YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER 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, EVER 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 individual's name. Commission mus otified of any arrests and/or convictions that may occur after the date of signing this application. ; O YES g NO f zt � 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 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? OYES ONO IF YES,list the name of the premise(s): Sege o d ►�' 3. Do you, as a manager, qualify under Nebraska Liquor Control Act (§53-131.01) and do you intend to supervise, in person,the management of the business? EYES ONO Form 103 REV MAR 2016 Page 4 of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued: tif,3"/1 4 I/C Name on Certificate: Tet 11 lvv; SCL4,ae4/4 Applicant Name ( Name of program(attach copy of course completion certificate) mmDate/YYYY) *For list of NLCC Certified Training Programs see training Experience: Applicant Name/Job Title Date ofName&Location of Business: Employment: 5. Have you enclosed form 147 regarding fingerprints? 'pYES ONO Form 103 REV MAR 2016 Page 5 of 6 t , PERSONAL OATH AND CONSENT OF INVESTIGATION 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 §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 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. I &VA Signature of Manager Applicant Signature of Spouse ACKNOWLEDGEMENT '— State of Nebraska County of � � t The foregoing instrument;was acknowledged before me this /4 Y 4 c l by � YrE�'ie<� SLC,OA. 'ye ems date NAME OF PERSON BEING ACKNOWLEDGED --- Affix Seal Notary Public signature GEMRALNOTARY-Sta1eofNebraska DENNIS CASTILLO My Comm.Exp.May 12,2018 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 REV MAR 2016 Page 6 of 6 Point-of-Sale Payments Page 1 of 2 pA el 0 it N[[MASK, .GO\: YOUR RECEIPT Nebraska State Patrol-Criminal Identification Division RECEIVED 3800 NW 12th Street, Suite A Lincoln NE 68521 (402)479-4971 MAY I 6 2016 Antonina.Anderson-Trumble@nebraska.gov Transaction Id: 10122422 1\11 .B �i uOR THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE C > ' ' r, ;SSi ,r{ Customer Name: TFL INC KAMOL SAMIEV Credit Card Number: **** **** **** nebraska total amount charged $147.33 Items Location Quantity Order ID Total Amount Liquor License 3 20674628 $86.25 Applicant Name: KAMOL SAMIEV Date of Birth: Last four digits Soc. Security Number: Liquor License 2 20674628 $57.50 Applicant Name: TAHMINA SAMIEVA Date of Birth: Last four digits Soc. Security Number: Total remitted to the Nebraska State Patrol -Criminal Identification Division $143.75 https://otc.cdc.nicusa.com/Publ icReceipt.aspx?src-_csli 5/1 3/201 ra SUBMISSSION OF FINGERPRINTS / PAYMENT OF FEES TO NSP-CID r Ir " RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH MAY 16 2016 PO BOX 95046 LINCOLN,NE 68509-5046 AgArit1.110 l UOR PHONE: (402)471-2571 ©ffic O !'{ ? i._ ;:" (:, 1 °'! FAX: (402)471-2814 Website: www.lcc.nebraska.gov Class: _._ License... Applicant Name: (Corporation,LLC, Partnership or Individual) Trade Name: 4 3o.v Q( (Doing Business ) 0°2) 399- 5 Y71 3as4iwx@ c,h,D3 Le3i Phone Number Contact E-mail Address L.1 DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • See Application Requirement Guide for listing of Fingerprint Requirements, found on our website under "Licensing"tab in"Guidelines/Brochures". FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REOUIRED PROCESSING FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIOUOR LICENSE. • This completed form MUST be included with your Liquor License Application and/or Manager Application or changes to: Corporate Officers or Stockholders, LLC Members,Partners or Addition of Spouse where new fingerprint cards are required(see New Application Requirement Guide). • DO NOT send fee payments to the NLCC—fees MUST be paid directly to NSP; Include a list of names covered by your payment to insure proper application of • Fee payment of$28.75 per person must be made directly to the NSP; It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp Or checks made payable to NSP should be mailed directly to the following address: The Nebraska State Patrol—CID Division 3800 NW 12tb Street Lincoln, NE 68521 • Fingerprints are not required for spouses that have no involvement with business- Spousal Affidavit of Non Participation (Form 116) is required in lieu of fingerprints. • 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 MAR 2016 PAGE 1 I. Name: NPM() L 3Q(YileV Date of Birth: Last 4 SSN: (Please print legibly) Fingerprints on file with the commission? YES 4 How was payment made to NSP? NINSP PAYPORT OCASH OCHECK SENT TO NSF Ck# 2. Name: —rah fA ‘1CL 5LIYITCV CAL (Please print legibly) . . Date of Birth: Last 4 SSN: — Fingerprints on file with the commission? YES KI How was payment made to NSP? ANSI) PAYPORT OCASH OCHECK SENT TO NSP Ck# 3. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES 0 How was payment made to NSP? ONSP PAYPORT OCASH OCHECK SENT TO NSP Ck# 4. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES 0 How was payment made to NSP? ONSP PAYPORT OCASH OCHECK SENT TO NSP Ck# 5. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES 0 How was payment made to NSP? ONSP PAYPORT OCASH OCHECK SENT TO NSP Ck# 6. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES 0 How was payment made to NSF? ONSP PAYPORT [WASH OCHECK SENT TO NSP Ck# I hereby certify that fees of$28.75 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): AA.,0 L 3 A-MC e_Aj Title: V Signature: .tiet) I I . Date: OSI 1V1 20 k, FORM 147 REV JAN 2016 PAGE 2 City o ®!I i�W/ i�W C� � N� OI�AHA, N O��, •6� � ` 1819 Farnam — Suite LC 1 Omaha, Nebraska 681 83-01 1 2 S'. r.rAi Buster Brown (402) 444-5550 �.o = , City Clerk FAX (402) 444-5263 0 ° 44, FE133 . June 7, 2016 TFL, Inc. Application to appoint Tahmina Samieva Dba"Mega Saver" manager of your present Package Liquor 2014 "L" Street License location Omaha, NE 68107 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 June 21, 2016 . 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, 4,414,‘ Buster Brown City Clerk BJB:clj H City ofOmaha, Wibrasfa .,,,, �o4NI,oMA A,N� G ' atteA4-, 1819 Farnam —Suite LC 1 .. '�r� tat I, Omaha, Nebraska 681 83-01 1 2 nVA4116:, ;, . ,L r OI. . fib..= 'r, Buster Brown (402) 444-5550 �o �'` " 25�-`' ty City Clerk FAX (402) 444-5263 04,, 46. �4ED FEBR3t June 7, 2014 Tahmina Samieva Application to be appointed manager of 13910 Cuming Street present Package Liquor License for TFL, Omaha,NE 68154 Inc., dba"Mega Saver", 2014 "L" 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 June 21, 2016 . 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, va— de , eld0), Buster Brown City Clerk BJB:clj No. 9Q 6 TFL, Inc., dba "Mega Saver", 2014 "L" Street, requests permission to appoint Tahmina Samiev manager of their present Package Liquor License location. 06-21-16;cj RECEIVED Presented to Coun il: June 21, 2016 - Approved 7-0 Buster Brown City Clerk