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RES 2016-0907 - Appoint Kamol Samiev manager of Mega Saver E-MAILED TO NLCC 2 2 -1 6, , Wr , "` 'it, '/;%\ STATE OF NEBRASKA (41.L.. 7.1.! Pete Ricketts 111:: 0 •• NEBRASKA LIQUOR CONTROL COMMISSION \ LIW‘ - Governor • Hobert B.Rope 41 hi -4 Executive Director -lor t**1 301 Centennial Mall South,5th Floor MANAGER IlEctiMMElifinATION PO Box 95046 Lincoln,Nebraska 68509-5046 • t_ v A Phone(402)471-2571 DATE: May 20, 2016 Fax(402)471-2814 or(402)471-2374 IRS USER 800 833-7352(TFY) web address,http.//www.lcc ne goy/ TO: Omaha City Clerk E-MAIL: carman.iohnson@cityofomaha.org MANAGER: Kamol Samiev LICENSEE: TFL, Inc. DBA Mega Saver LICENSE#: D-060698 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 tracy.burmeister@nebraska.gov or fax to(402)471-2814,with questions call (402)471-2572. X APPROVED NO LOCAL RECOMMENDATION DENIED COMMENTS: e /4 Ise/ (may attach minutes and/or additional notes) CLERKS SIGNATURE: DATE: 0,/0.1-el0 I H u _im, II 1600009888 Janice M.Wiebusch Robert Batt Bruce Bailey Commissioner Chairman Commissioner An Equal Opportunity Employer MANAGER APPLICATION Office Use INSERT-FORM 3c 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.Ice.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 officer, 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 Spousal Affidavit of Non Participati In 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 1 of 6 MANAGER APPLICATION Office use INSERT- FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOU'I'H PO BOX 95046 LINCOLN,NE 68509-5046 PHONE:(402)471-2571 FAX: (402)471-2814 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 S jN:p+�'i `•; # '.2. �, � � �; 6�`c"° r�i a "5 k�,�Yy�".k d`� rt"I f .Y 1 ��� �ft„4.1, 4/' :h`.. Name of Corporation/LLC:TFL, Inc. (S.o.S.# 10045933) y t c yr. �! e ti � d � 4� 7�, f x .k" � , .y � PreMi i o n ,aW 1 ?.. . : :.a..;. � � :.� ' . ter > ; 6 Liquor License Number: T 0(00L9q .8. Class Type E (if new application leave blank) Premise Trade Name/DBA: (\el ll Premise Street Address: 131 IL.) street City: 0( G�, County: DoctIcts Zip Code: COIL I Premise Phone Number: ( 1CL) " E 3 L _ 0-/ t ) 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 inforration here. SIGNATURE REQUIRED CORPORATE OFFICER/ 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: !V)le V First Name: fl(VA MI: Home Address: 12,0111 Diy\nek. 5re City: k, victl\c‘. C( County: NLt-Cf)) .S Zip Code: (c.) Home Phone Number: (.L132.) 2_06 - t I Driver's License Number& State:_ N F- . Social Security Number: 0 (c3 Date Of Birth: Place Of Birth 1 61. k SI 4‘11 • Email address: 444,IY\ \./ yr.„ e cowl iFrail*:WO(E*iifa spousal affidavit has bOti submitted) j23 YES Ej NO 'irfc1' iVama iatIbiH : 'F4t— Ift,..k.,L ‘ Spouses Last Name: '‘OlVl lk,),V EA- First Name: 1-6t(Z-Onct. MI: Social Security Number: Driver's License Number& State: t\1 rt7:5 Date Of Birth: Place Of Birth: —1-"*C-qi I ck V ) 01C ',19-1V4 e 571"-kP, :VA; Pi:1J!) h1/4. OR THE PASTTEN(1O) YEARS '.1*, A, POUSE YEAR YEAR CITY & STATE YEAR CITY& STATE YEAR FROM TO FROM TO UIVICIACk. t\i F_.-, Mci61 12-01ko °M - ak N 2.0N 20 IL, v 0 t-iflutizod totTri*.o. Nt-1 2.0i9 Form 103 REV MAR 2016 Page 3 of 6 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 taw; 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 must be notified of any arrests and/or convictions that may occur after the date of signing this application. ►:1 YES n 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 - at2,21 Uti1046, N\O \jaVA e6PAic-4 c6t\Oi\os D\t(Wt.\e‘Rt\)17:.- 0‘.1124. CbV\4Ptl)rd POD cl ictvi 111 S r t‘ 25\oz vittfcc, (szwc,) rotelt - t, 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? AYES r NO IF YES,list the name of the premise(s): Set Ot -C \iS 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? AYES PNO 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: eX.)la Name on Certificate: -41 W \ .5) M 1 Date Applicant Name (mm/yyyy) Name of program(attach copy of course completion certificate) *For list of NLCC Certified Training Programs see training Experience: Date of Applicant Name/Job Title Name&Location of Business: Employment: • 5. Have you enclosed form 147 regarding fingerprints? II YES ONO Form 103 REV MAR 2016 Page 5 of 6 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. l'he 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. Signature of anager Applicant Signa rf Spouse ACKNOWLEDGE'"ENT State of Nebraska County of tg(c3'CLS The foregoing instrument was acknowledged before me this —/ (t by Lto iI 5a pi;C i G Farzana kr,;lpua date NAME OF PERSON BEING ACKNOWLEDGED ` 1 1 Affix Seal Notary Public signature F &MAL�A Staff Nebraska MILLER ,t .iJ" My COSMO.f.Saptent&4,201.`. 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 Print Form SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT 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 kc nc.gov (":140F I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any interest;directly or indirectly in the operation or profit 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 or represent myself as the owner or in any way participate in the day to day operations of this business in any CatitteitY. I understand my fingerprint will not be required;however,I am obligated to sign and disclose any information on all applications needed to process this FARZONA KOMILOVA Signature o ing for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) State of A/ re—S)6:1/4 County of The foregoing instrument was acknowledged before me this 5-120) by date name of person acknowledged Affix Seal 4 GENERAL NOTARY-State el Nebraska al DELMAR D CRYEF1 I aNt-Mi My Comm.En,NOV.22.2017 acknowledge that I am the spouse of the above listed individuaL understand that toy:siousa and.1 are responsible for compliance with.the conditions set out aboVe. If it is determined that the above above has violated(§53-125(1.3))the Corn ion may cancel or revoke the liquor license. : : : • - • KAMOL SAMIEV Signa ure of individual involv ith application Printed name of applying individual (Spouse of individual listed above) State of A) re.,A\C-45. County of ,/:>„„.„5\,( The foregoing instrument was acknowledged before me this 5-/20 I ) by )4,•• Sc * date name of person acknowledged Affix Seal GENERAL NOTARY-State of Nebraska • DELMAR D DRYER My Comm.Exp.Nov.22.2017 In compliance with the ADA,this spousal affidavit 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 35-4178 Revised 1/2008 -6(:0- C tir 2.,...-C/ p I Print Form SPOUSAL AFFIDAVIT OF °Mee uRECE1VED NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION M AY 1 6 Z016 DEC 2 2014 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509-5046 ikT7,rs'', 1`,`744;,' t 1 1CWOR PHONE:(402)471-2571 1....1.: .1 . 0.,0 FAX(402)471-2814 ri ,, c y-q0,11t4 :1',P,c"cil.,.. .Lfir°,,11,°31 * I r• L t is i -.1 - Website: www Iccite.psv ! I acknowledge,that I am the spouse of a liquor license holder. My signature below confirms that I will have not have any interest,directly or indirectly In the operation or profit 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 or represent myself as the owner or in any way participate in the day to day operations of this business in any capacity. I understand my fingerprint will not be required,however,I am obligated to sign and disclose any information on all applications needed to process this application. : &4011 _....:,/ i ...,, . PAr2.0na. kOrni 10 VA .4, Signature o spouse asking for waiver Printed name ofspouse asking for waiver (Spouse of individual listed below) State of Ai&rairaA County of Do+110,3 The foregoing instrument was acknowledged before me this 11141 ;ON by 1r2DA4 LO tivt:1 0 tic/ date , name apemen acknowledged .., ABU Sell i imj?(EPERAL 140TARY-We of*temp NAIN'otary Pubtjlk s f't ure SHANE W.COSTELLO II My Coriim.Exp.Oct.14,2015 . . I acknowledge that Jam the spouse of the above listed individual. I understand that my spouse and(are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-125(1 3))the Commission May an,*1-pr revoke the liquor license. . .1 nl-leNi Signature of ndividual iniko ved with application Printed name of applying individual (Spouse of individual listed above) State of /14eLf4i6A County of 00vIu 5 The foregoing instrument was acknowledged before me this 'I A.1.11/014 by 11-.4"" t 5 ifv%I VI date name of person acknowledged kei 4ZE /t' MTh.St4 asteGelERN.NOTARY-Steed Netraska SHANE W.COSTELLO n 1 otkuy‘Public signature My Coin.Exp.Oct 14,2015 1 In compliance with the ADA,this spousal 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 I .1 !I ;,I , IIIi il u PORevRiMsed35-41,2008i 18 I , , 1 , , 1600000588 SUBMISSSION OF FINGERPRINTS / PAYMENT OF FEES TO NSP-CID t 1\rt) RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH MAY 15 Z016 PO BOX 95046 LINCOLN,NE 68509-5046 `7 )OR OfficJky PHONE: (402)471-2571 CONTRO' FAX: (402)471-2814 Website: www.lcc.nebraska.gov Class: License#: Applicant Name: I FL C (Corporation,LLC, Partnership or Individual) Trade Name: i),( 0,A,„1/4., 300/ (Doing Business Ms) ( °2) S6.- 51 mevKCD Phone Number Contact E-mail Address 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 REQUIRED PROCESSING FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR 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 payment. • 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 12th 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. Name: RtY1,01 X11Y leV Date of Birth: _ , Last 4 SSN: (Please print legibly) Fingerprints on file with the commission? YES How was payment made to NSP? NINSP PAYPORT OCASH OCHECK SENT TO NSP Ck# 43 2. Name: --ra PA" VI,C 5Carce (Please print legibly) r Date of Birth: - Last 4 SSN: Fingerprints on file with the commission? YES 71 How was payment made to NSP? KNSP 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? 1:1 N SP 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 NSP? ONSP PAYPORT OCASH 0 CHECK 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): /WM_ 3&Me \,/ Title: \s/ Signature: 2LL1 Date: Si )20 it FORM 147 REV JAN 2016 PAGE 2 Point-of--Sale Payments Page 1 of 2 YOUR RECEIPT Nebraska State Patrol-Criminal Identification Division RECEIVED 3800 NW 12th Street,Suite A Lincoln NE 68521 (402)479-4971 MAY 1 6 2016 Antonina.Anderson-Trumbleenebraska.gov Transaction Id: 10122422 N 7 ,A -!QUOR THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE Customer Name: TFL INC KAMOL SAMIEV Credit Card Number: ******** **** nebraska total amount charged $147.33 Items Location Quantity Order ID Amou Totntal 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 htlps totc.cde.nicusa.corn/Public12eceipt,aspx?src-csh 5/13/2016 Cttyof OmaFtal Nebraska . 43, oMAHA/N �+Q9 1819 Farnam — Suite LC 1 zrorlettj ;11 t Omaha, Nebraska 681 83-01 1 2 Buster Brown (402) 444-5550 r,, City Clerk FAX (402) 444-5263 Q 4 4rFD FEB10* June 7, 2016 TFL, Inc. Application to appoint Kamol Samiev Dba"Mega Saver" manager of your present Package Liquor 10780 "Q" Street License location Omaha,NE 68127 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, Buster Brown City Clerk BJB:clj City o O// �-al uz pMANA, N ebras a Alwillil `7 C1 1819 Farnam - Suite LC 1 � `'k .._(?, *'r� Omaha, Nebraska 681 83-01 1 2 nV �. lri4r l Buster Brown 9''" ' _'44., (402) 444-5550 �� City Clerk FAX (402) 444-5263 0 4P U�'��ry FEBR June 7, 2014 Kamol Samiev Applications to be appointed manager of 12917 Binney Street present Package Liquor License locations Omaha,NE 68164 for TFL, Inc., dba "Mega Saver", at 10780 "Q" Str.; 3402 So 72nd Str. &8928 Maple Str. 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, -4. ti ldg9.44: Buster Brown City Clerk BJB:clj No. 99j 1 TFL, Inc., dba "Mega Saver", 10780 "Q" Street, requests permission to appoint Kamol Samiev manager of their present Package Liquor License location. 06-21-16;cj .l RECEIVED Presented to Coung}'l: June 21, 2016 - approved 7_6 Buster Brown City Clerk