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RES 2016-0787 - Appoint Rusty L Newcombe manager of Eddy's #550 E-MAILED TO NLCC - — MANAGER RECOMMENDATION Wry - DATE: May 6th 2016 cry r ' TO: Omaha City Clerk MANAGER: Newcombe, Rusty LICENSEE: GPM Midwest 18 LLC dba Eddy's#550, 11919 Fort Street, Omaha, NE 68164 LICENSE#: B—116311 DUE DATE: 6/6/2016 Attached is a copy of a new manager application submitted to Nebraska Liquor Control Commission. Please complete the following to submit your recommendation. Please email back to Brenda Hiland or fax to (402)471-2814,with questions call(402)471-2573. APPROVED NO LOCAL RECOMMENDATION DENIED COMMENTS: l.. C..-� 0 'J J NV't Nt C` S , 01 7 �j1 (may attach minutes and/or additional notes) CLERKS SIGNATURE: DATE: � �Q/4 MANAGER APPLICATION Office Use RECEIVE® INSERT-FORM 3c C NEBRASKA LIQUOR CONTROL COMMISSION MAY 6 2016 301 CENTENNIAL MALL SOUTH PO BOX 95046 NeRASKA rxo�lvE N4oij¢�i is��� CANT RGL COMM S�R FAX:(402)471-2814 MISSION 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 1.47 for further information,read form carefully to avoid delays in processing,this form MUST be included with your application V 21 years of age or older Name of Corporation/LLC: al(Y) h '}d Wt I P, Liquor License Number: 1 6'7J}1 Class Type P (if new application leave blank) Premise Trade Name/DBA:E.C101 G S Premise Street Address: I t a}I � Sind City: Omakiok County: DbiAl las Zip Code: 164 Premise Phone Number: (4o ) 431- 1"!i 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. 4)00 bov+all Baste!I cF0 SIGNATURE ltEQ. ' DrB Y CO ktittkTE Q1.FIGER/MANAGING iMIEMBER (Faxed signatures are acceptable) III II 1 II 1111111 III II Form(03 REV MAR 2016 Page 2 of 6 1600008516 RECEIVED MAY 6 2016 It T: , fE�l: ) :fr�` r l' 1 ! t -1'r:; " OMMISSION Lan Name B,a tate)rv►b e. First Name: 11a MI; L. Home Address(include PO Boa if applicable): 117 24 �Grr r r Au ' City: Dnu County: t45 zip Coca: 816 y mane Phone Number: yol)c9 ,-'i LL7 Baalness Phone Nwnbet: '!c 13 y-4+11 j Boole!SecurityNcinibbor ---prima Lioona°Nurclber&Stats: , LIYE Bate OfBirlb.:_ Mao Orfhirth:_ ,Ar.u, J' p Email address (IAA LI it)w.i5 c.7.. J 9 le ,co AT Ate' allo Spouses Lest Name: , 1 ,a t Q w►ir a First Name: 7e'N A-/' MI: L•-• SoelaiSeourityNamber„ T _ _ Dr3veraI.icea►aoNumber dk State: Date Of Bhiltt:. Place Q1Birth4 J3,./I4. 4).e. A'tp , R CITY&STATEYXAL t CITY'&STAa'ItISOM TOi r YEAR J�tOiii mMum,1 me _ , Lo j/ La)b _ At£ _ 2.aI/ 2016 AL.„ . N , lacy? Elm A11<. • 7,..rs1c 240.? a�+,�/,� /.jb= looS 1.407 Pena 103 RSV R01R2015 RECEIVED MAY 6 2016 : : • ,-• LIQUOR • FROMA TO NAME OF EMPLOYER .:N.AME OF SUPERVISOR TELEPHONU R j5 2'/b G.s-S I I+ Pr rimy up ke.-4 y027 y3 y-owl/ 2(.7t2 15 « , rn'cs-., IuA I/ 2) 3J1' s7/l 1, READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY. Must be completed by both applicant and spouse,unless spouse has flied an affidavit of non- ' participation. Has anyone who is a party to this application,or their spouse,)tVSR been convicted of or plead guilty to any charge. Charge means @gy 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. Also list any charges pending at the time of this application. If more Than one party,please list charges by each Individual's name. a YES ❑ NO If yes,please explain below or attach a separate page. Date of Where Description Name of Applicant Conviotton Convicted of Disposition 11 =+ ` (mlmlyyyy) (City dit State) Charge RNA i j MCI.J.4,4 - +f'/ ii dlhe►l�ilYP SGIJIn� (V—MC*19t f!0G 2. Have you or your spouse ever been approved or made application for a liquor license In Nebraska or any other state? DYBS [ANO IF YES,list the name of the premise(s): 3. Do you,as a manager,qualify under Nebraska Liquor Control Act 053-131.01)and do you intend to supervise,in person,the management of the business? AYES ONO Patin 103 RIM JUNE 2015 Page 4 at5 r&\cia. l \ s 1L.QsL �.� .�, • (z.1 r�--, LX c as 6— \ (p-3 I / R`51/ NC lombc ! • °'s 't -,O ,‘V;ki TWO G Lfsr) ®. f� .h.& 1io 4 f f 4 d-r Oro Al_ A yin l 2-6o3 6n.4 AloUtMl€P 2 J 4.,,A .1 tr.,,.0 ).,,/ /•/�1CI / [ 0•) f'�ri��n7� For bon, o ffrAJ J a l/c.,lc loa j,,c- 7h .$ o t 5.A .;..A t Li ty a_ fo f r ' t Lo4i%Ira-1'0,1 to Y e-r/ tc-1J{.cam r lrgjc f'ef I/e Con v4 r".0 S m il�ci/ Net.) co,,aC `-(offs - S CI AL...A.0,b - Loo7 e 74.00•io"� RECEIVED MAY 6 2016 (NEBRASKA LIQUOR 4, Llet the alcohol related training and/or experience(when and wharePooifl�garlaIDIMOSJON r . . *JdLCC Training Cattitioato leaved: tom-. Name on Certlflca: • . - ApplloantName Dat° Name of program(attach copy dowse oomplettoncertIgcate) 'For list ofNLCC Cordrled TrahlIngPrOpoons soo Bxpedenoe: _ Applicant Name/Job Title Employment; Name&Looation of Business: • 5. Have you enclosed Form 147 regarding fingerprints? OYES pNO - Porn tin xevnrNesors• Pose s af6 RECEIVED MAY s 2016 CONTROL COMMISSION The above individuai(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§53-13 1,01)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. Signature o Manager Applicant Signature of Spouse ACKNOWLEDGEMENT State of Nebraska County of - L kl to 1p The foregoing instrument was acknowledged before me this r .� _ by2/4- NAME OY PERSONBEING ACKNOWLEDGED Affix Seal egiemainiti itobn,•Stair of Nebraska ' Notary Public signature YVONNE OLANKENSHIP NY Comm,Elm.Mar.10, Li 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 R13Y MAR 2016 Page 6ot& SPOUSAL A»FYUA'VYT OF office use RECEIVED NON PARTICIPATION INSERT NBEIRA3KA LIQUOR CONTROL commis mom MAY 6 2016 301 CENTENNIAL IMALI.SOtTI7t PO BOX 95046 LNcOLN,NB6115094046 NEBRASKA LIQUOR PHONE(402)471-2511 FAX(402)471-2814 CONTROL COMMISSION ywobs te:www.ice ra anv .I 1�.il tte,' �,t i F,i, i;i ili :' ,�6 h'.}h ,Y1 t'a I� i lilsll`'.� :+' tt.'l iii"� ! n �� lYt 47 V e. 4 i,t tr S 1 lz,-2. y • ' �I'Y[ Il �� �' t t<'-N-1`l�w�g ti iifie. ,�!lo'til�_f 9L,A! c Ili ''t..,1,, , ,{.t (i14ri 1hi h L.',,'.'tpl f>>)Ii t 7 1, I1 Iili I I ,l5 Ih It t I. 5`I3eI t� it.) I 1t�n°j J°1 "'J i('',j 1:' tt)11.11 ')..it I ' I tr7 p , t•i t1 ,r1 q i 'Oil h is _ ;r' 'IOW :r tt 4 �r �, ct 1 ,0¢�--tr t f. e it s l '-J Y t.Ttl r,�( )� `n a . '' a j�'".•t,i . I 1 1 *✓i tI, '(� 1s ,.,�t I,;',, °4,,_:.,,il., it,,,t ling 1_�/I t 1� tt1 , .trl ''illn t•�filiit ie ' 41,LI1^J ♦. x • 4 Ii , , 1r I_ '' i 71t t 1' t l It n� i 11 r, 13: 111 n1, i 1 Its+ 1 f 11i e, if 6 s i w aq J gill 1'?i:Jt 1•"ti of 31Y� . ,_ I ' _ .. , } t i'7,tt ., ;.. 5 'Is= !;, !. - .a, *,, s'`?. ° ;PW' __3g:,. ...._jj,ty,....,t...L.A.,---..-- ),Z,Ttk ger 1.4.x....)14)vr.be.... ature of spouse asking for waiver Printed name of spouse asking for waiver (Spouse of individual listed below) ..---- State of `'�Re)County of • �, The foregoing instrument was acknowledged before me this IV ����°�7 by `iG�¢trlr��. V I! l'Grut..rk .��C:)C I e Mate of parson acknowledgedf CC. • & ..r. —. Ir •• Affht Seatisie.Qefllril Retail-Siaie of Rebooks* ' Notary Public signature YVONNE BLi NKENSHIP My Commtftp.Mar. 10,10z0 ,-r4r i 1 tyl{1rf „t -1 - i>,t i.,i I I, 'aZti I..sr iv, 1a,itij1 1 IE`7Y-.ri[•.c qi i, j)111 t cji n/it '.i I 11 Fi . 1i Ii4jl �r}',2' tin fit•!1 i fI jllt1 tl Et (,i, t7 i,;lilt tl I r iE I1,P ''i'-• Ik - t tin�t iI 11.9, I I t Ill ��''S�ait tS �YriY ji� ,,- _ i, ,t,i 111n, t, � r'i it.��4.1•.,1.5i{.1 ' Ct I I I.,1-1S tJt1,1i'i.,..-_,. . •,.Fl, tS.+ _:'i 1 z'L. ., .. .d'.1y:,'. -r-43s4„'1i)sIf; �,.0 1;1' KL•SIN/ Ner.-✓en4. e Signature of individual involved with application Printed name of/applying individual (Spouse of individual listed above) State of County of The foregoing instrument was acknowledged before methis o'O! .v. by______ G tub?al —' name ofperson acknowledged Affix sue Costal Nola* of Ilsbtaslla HIP " otary Public signature tit.r"x YVONNE�a o 2029 I compliance with ao AOA,this opoaseI affidavit often pastielpati on is available In other fantods for personsdisabilities. A ten day advance period is requested in writing to produce the alternate format P°rs0 with FORM 35.4176 nevbed 312008 SUBMISSSION OF FINGERPRINTS / RECEIVED PAYMENT OF FEES TO NSP-CID DATE RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION MAY _$ 2�1� 301 CENTENNIAL MALL SOUTH NEBRASKA LIQ(JQ(� Po BOX 9,NE 046 CONTROL COMMISSION LINCOLN,NE 68509-5046 Office Use Only PHONE:(402)471-2571 FAX:(402)471-2814 Website:www.lcc.nebraska.gov Class: License#: Applicant Name: GPM Midwest 18, LLC (Corporation,LLC,Partnership or Individual) Trade Name; Eddy's#550 (Doing Business As) 401 ) 431 — 0491 cmcginn@gpminvestments.com Phone Number Contact E-mail Address DIRECTIONS FOR SUBMITTING FINGERPRINTS AND I'EE 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—CD 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 RECEIVED MAY 6 2016 NEBRASKA LIQUOR CONTROL COMMISSION 1. Name: )�.\5 Ate,.A, ri-.1( Date of Birth: _ t 4 SSN: (Please print legibly) Fingerprints on file with the commission? YES 0 flow was payment made to NSF? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP Ck# 2. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES ❑ How was payment made to NSP? DNS!)PAYPORT ❑CASH UCHECK SENT TO NSF Ck# 3. Name: (Please a print legibly) Date ofl3irth: Last 4 SSN: Fingerprints on file with the commission? YES© How was payment made to NSF? ❑NSP PAYPORT 0CASH ❑CHECK 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? QNSP PAYPORT ❑CASH CICHECK SENT TO NSP Ck# 5. Name: (Please print legibly) Date of Birth: Last 4 SSN: Fingerprints on file with the commission? YES ❑ How was payment made to NSP? ❑NSP PAYPORT 0 CASH QCHF,CK 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? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSF Ck# I hereby certify that fees of$28,75 peer 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): Rt.5 9 7/e Title:_ Sc 14,4 P11*-1"4 r Signatures � Date; ' rl FORM 147 REVJAN 2016 PAGE 2 Cityof OmaFta Nebraska 4oMAHA N� 1819 Farnam —Suite LC 1 z ^a Omaha, Nebraska 68183-0112 n „,:�1J �1 ) (402) 444-5550 �A` � ` Buster Brown City Clerk FAX (402) 444-5263 0� -- T4D FE1303' May 24, 2016 GPM Midwest 18, LLC Application to appoint Rusty L. Newcombe Dba"Eddy's #550" manager of your pending Off Sale Beer 11919 Fort Street 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 June 7, 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, do:140?„,Atais Buster Brown City Clerk BJB:clj City ofOmaha WibrasI oMAHA /, 4,__ AvA„,,,s,„„ v ; 1819 Farnam — Suite LC 1 0 Omaha, Nebraska 681 83-01 1 2 �� �l �NI M Buster Brown (402) 444-5550 ��� ✓ City Clerk FAX (402) 444-5263 o4), R��4�ry FEB May 24, 2016 Rusty L. Newcombe Application to be appointed manager of the pending 11724 Camden Avenue Off Sale Beer License location for GPM Midwest Omaha,NE 68164 18, LLC, dba"Eddy's #550", 11919 Fort 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 7, 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 K/1( No. 71/ GPM Midwest 18, LLC, dba "Eddy's #550", 11919 Fort Street, requests permission to appoint Rusty L. Newcombe manager of their pending Off Sale Beer License location. 06-07-16;cj 3 0 / LJ V RECEIVED Presented to Council: June 7, 2016 - A�} r tied �-/ y f4V Buster Brown City Clerk