RES 2016-0907 - Appoint Kamol Samiev manager of Mega Saver E-MAILED TO NLCC 2 2 -1 6,
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'/;%\ 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