RES 2015-1601 - Appoint Lonnie G Eggers manager of Nuestra Familia Supermercado #733 E-MAILED TO NLCC 1.
r _ / ..
...---,:cos.sryT `°, STATE
OF NEBRASM
) p4 u".,. ri �♦ LIQUOR
CONTROL COMMISSION
Robed
,.. - .- y; Executive . upe
:,t f?c Y M:
Pete Rickettsi 5th Soo
r
'. Governor ' r v, r-it 301 Centennial-Mall'South,
r t _ _ ,\ P.O,Box 95046
599 iO4b
'. * to•" " ''.'1, N. t A " ! Cinema,Nebraska 471-2571
Phone(492}
MANAGER RECOMMENDATION Fax(40 )471-2814 or(402)471-2374
TRS USER 800 833-7352 TN)
web address;http.1/www:lcc.ne.gav/
DATE: December 2,2015
TO: Omaha City Clerk
EMAIL:carman.iohnson ci o a .or
MANAGER: Eggers, Lonnie G
LICENSEE:
SEE Kinky Dinky Supermarkets dba Supermercado Nuestra Familia#733
LICENSE#: Class C-105981
DUE DATE: January 16,2016
Attached is a copy of a new manager application submitted to Nebraska Liquor Control Commission.
d
to
Please complete the
following to submit your recommendation. Senbackll Shannon N hoff at
Shannon n Koff ebraska. av or fax to(402) questions
471-2814,with
2.
)SL- -- APPROVED CCID#1601 DECEMBER 22, 2015
NO LOCAL RECOMMENDATION
DENIED
COMM ENTS:
i
(may attach minutes and/or additional notes)
CLERKS SIGNATURE:
DATE:
Bruce Bailey
Robert Batt ntnissa Bailey
.1 M.Wiebasch Chatimo+i'
Commissioner_
An Equal Opportunity Employe*.
11n l(%
Office use
MANAGER APPLICATION � �V
INSERT -FORM 3c
NEBRASKA LIQUOR CONTROL COMMISSION
DEC 41 2015
301 CENTENNIAL MALL SOUTH �SEBRASKA LIQUORPO BOX 95046
LINCOLN,nIEb8509-5046 CONTROL COMMISSION
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.nebraska.gov
Mana er must:
a corgi_ uer.corporate officer
•
Complete individual of the
with the Liqlication. uor Control Commission
must be an indlvldu
•
Fingerprints are required. See Form 147 for further information,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 with application
Spouse who will not participate in the business, spouse The
• Complete the Spousal.Affidavit of Non Participation
the manager completes the bottomnsert(must be )half. Be sure to
non-
participating spouse completes the top
complete both halves of this form.
• Need not answer question #1 of'the application
Spouse who will participate in the business,the spouses ust:
• Sign the application
• are required. See Form 147 for further information, this form MUST be included with
Fingerprints
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 JUNE 2015
Page 1 of 6
. .
MANAGER APPLICATION office Use
INSERT-FORM 3c
1:1 CENTENNIAL
BAICIA4UO1*1.4.1
COMMISSIONACLOLNSTORuOTEH ECEIVEP
PO BOX 95046
LINCOLN,NE 68509-5046 OE C 0 1 2°15
PHONE:(402)471-2571
FAX:(402)471-2814 NEBRASKA LIQUOR
Website:wwvvice.nebraska.gov C. 11 * 0
MUST BE:
V Citizen of the United States. Include co of US birth certificate naturalization nanrJ
current S passPoLt 63
V Nebraska resident Include copy of voter r istration in the State of Nebraska
V Fingerprinted. See Form 147 for further information,this form MUST be included with your
application.
V 21 years of age or older
:•;274,4777:7477;;;04,„;'
Hinky Dinky Supermarkets
Name of Corporation/LLC: - _
.1•;,-.,ttr,,,v1:.,,,:. —,',., ''-4,, „,,-,..4',":„":? ‘,,, . .,,kw, ie,',44 tftn1,1'4'::, :„, 'P P .' ",,2 ',orr;',',"4,:4 '.— ''''1,:„: 0# 400tiik-,
105981
Liquor License Number: Class Type____ _C (if new application leave blank)
Premise Trade Name/DBA:Supermercado Nuestra Familia #733
. 2900 Leavenworth Street -."'6 .--
Premise Street Address:
c ity:Omaha , Douglas
County: 68105
Zip Code:
402-346-2447
Premise Phone Number:
Email address:nancY-kimball@spartannash.com
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. Click on this link to see authorized individuals.
htt ://www.lcc.ne. ovilicens searchflicsearch.c i
SIGNA Mrs" QUI! D BY CORPORATE OFFICER i MANAGING EMBER
(Faxed signatures are acceptable)
1\1111111 111
1500025859 Form 103
REV JUNI,2015
Page 2 of 6
k ...
. 1
7
Last Name: 42.ks First
Home Address(include PO Box if applicable): 0 ;Z Ild- e_l_______---_
S I?,
City: C,
County: Zip Code:
Home Phone Number: - - Business Phone Number: 4 2.
Social Security Number: Drivers License Number&State:
_
,
Date Of Birth:_. Place Of Birth: (14--
... .
Email address: . G r 1\)ash.. coty)
tY4'YES 0 NO
Spouses Last Name: ,Q. First Name: 14'1 11 MI:_g__
Social Security Number: _Drivers License Number&State:
, 4
Date Of Birth: Place Of Birth: 1 1 NkS •
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1111111:111141111 YEAR YEAR CITY & STATE YEAR YEAR
FROM TO immuilii. FROM TO
INWIIIMINIIIIIIIne MT IIIIIIIIII
11111 IINIIIMIIIIIIII 111111
IIII....I.I...u....... --IIIIIIIIIIIIIIIIIIIIIMIMIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIII
IIIIIIIIIIIIIIIIIIIII 111111111111111111111111111111111111111
V
0 1 2015
NEBRASKA LIQUOR
CONTROL COMMISSION
Form 103
Page 3
REV JUNE 2015
of 6
1
ff
YEAR TELEPHONE
NAME OF EMPLOYER NAME OF SUPERVISOR
FROM TO NUMBER
TOO'S ES ty i i aol
iffErffigiVA ti S goal
(152-1144 -2, 30
-124
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 at._..1vi_pne.who is a party to this application.,or their spouse, alit,been convicted of or plead guilty to any ch_l _r e.
means aj,:i_v charge llegiial 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.
D YES A NO
if yes, please explain below or attach a separate page.
Date of Where Description
Name of Applicant Conviction Convicted of Disposition
m
ini (Ci &State Char e
illi"I"IlliIll. I. 11111111111111111111
1111lMIIIIIIIIIIIIIIIIIIIMINIIIMNIIIIIIIIIINIIIIIIIIII
illNIIIIIIIIIIMNIIIIIMIINIIIIIIMMIIIMIIIIIIIIIII
IINIIIIIIIIIIIIINIIIIIIIIIIIIMNIIIIIIIIIIIIIINIIIIII
IIIIINIIIIIIIIMNIIIIMIIIIIIIIIOINIIIIIIIIINIIIIIIIII
INIIIIIIIIIIIIMNIIIIINIIIIIMIUIIIIIIIIIIIIUNIIIIIIIIII
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
DYES *0
IF YES,list the name of the premise(s):
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?
EC IV •
DYES C4NO
, (i
NEBRASKA LIQUOR
CONTROL COMMISSION REV JUNE2015
Page 4 of 6
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NL_S_C Training Certificate Issued: Name on Certificate:
Applicant Name Date Name of program(attach copy of course completion certificate)
min/
111111111111111111111111111111111111111111111011161.11111111111111111111111111111111
1111111111111111111111111111111
11111111111111111111111111111.11111.111111111.111111111111
111110.111111.111111111111111.1111.1111111111111111
11111111111111111111.111111.111111111111111111.1.11
*For list of NLCC Certified Training Programs see www.lcc.ne. ov/trainin info.html
Ex.-rime: Date of
Applicant Name I Job Title Name&Location of Business:
Em,lo ment:
11111111111111111111111110111.111111111111111111111111111111111111111
111111111111111111111111111111.11
111111111111111111111111111111
1111111.111111111111111111111M11.11101.11111.11
5. Have you enclosed Form 147 regarding fingerprints?
OYES ONO
Form 103
REV RINE 2015
Page 5 of 6
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
I
i
ignature of Managei A ornt Si ture of Spo
ACKNOWLEDGEMENT
State of Nebraska
County of The foregoing instrument was acknowledged before me this
Z3 2-4
date name of person se o edged
/
Affix Seal
le sigpature ..e" "': DARDLyt4 D.moue I
' f::717::4 W COMMON MKS 1
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.
R EC Ti
NEBRASKA LIQUOR Form 103
CONTROL CO MISSION
REV JUNE 2015
Page 6 of 6
I
Print FO"-..
R E.
SPOUSAL AFFIDAVIT OF Office Use
NON PARTICIPATION
TION INSERT
RSKA LIQUOR
rket
NEBRASKA LIQUORCOSTORUTOLHComMISSION
301 CENTENNIAL MALL
ROL C'
NotAISSION
‘,„,,,fw
PO BOX 95046 9_5046
,,i
LINCOLN,NE 6850
PHONE'(402/471-2571
FAX.(402)471-2814
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Website ww.A.l..ef,..8ealLy
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,,-,,ii12,,t i , ,._Ate ,w,* *,,:2,..P...::wwwWwww•- ''''` '•;*• i0-.4,44;4.410w.,„* - ;7:N7...'•*,;iii,w.iw ,•••••"',t1.1•.',.''.*:'7:•*,VAlf:-.**.t..*•4i 11 i.,,..• 'e,t,,•._.,,,,,-,-- ,_
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Printed name
Signature of ssesliciism below) spouse asking fo iv er
(Spouse of Individualp
State of_PIS-19
County of ____.__ __
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The foregoing instrument was acknowledged before me this
a V
n a
ame of perirson::oThoutewled Jr
'EXPIRES ;
.-/— la MY COMMISSKX4
Lowi'd4401000"..m°""."".. ..
Nam Pu iic signa r
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Signature of indiyiddual liitsttveodivabedov ),._. , plication Printed name of applying
(Spouse of inch's,' ua
_
,
State of_____ -____
__s,... $ 4 :- -- -------4-------- LO Ali"
County of ____
person ackno ',8ed
' 6 ril 44 .71 it,.., by
2 3 , - name of
The foregoing instrument was aicknowledged before me thii.
/11 cAROLYN gri"°‘14°..,,,,mica
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--**/
'•
Not.• Public s II •
t.. - .
FORM 35-4178
with the ADA,this spousal ,
to produce the alternate
Revised 1/2008
In compliance w .0d as requested in writing
A ten day advance Peri affidavit of non participaonsfoavrmiUalatble in other formats for persons with disabilities.
•
SUBIVIISSSION OF FINGERPRINTS /
PAYMENT OF FEES TO NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION rE: 0 2015
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRASKA LiQUOR
LINCOLN,NE 68509-5046 4. • It!OMISSION
PHONE:(402)471-2571
FAX:(402)471-2814 "11111112
Website: wwwice.nebraska.vb,
Applicant Nanie: U Save Foods, Inc.
(Corporation,LLC,Partnership or Individual)
Trade Name: See Attached list
(Doing Business As)
(616) 878 - 2785 nanc .kimball spartannash.com
Phone Number Contact E-mail Address
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
• See New Application Requirement Guide for listing of Fingerprint Requirements, found on our v,cbsitc
under"Licensing"tab in"Brochures".
• 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.
• Fee payment of$28.75 per person must be made di_ssyeti to the NSP;
You may submit the payment through the NSP PayPort online system at .ne. ov/ o/ns
or checks made payable to NSP should be mailed directly to the following a
The Nebraska State Patrol—CID Division
3800 NW 12th Street
Lincoln,NE 68521
• 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.
• This completed form MUST be included with your Liquor License Application and/or Manager
Application or Changes to: Corporate Officers or Stockholders, LLC Members, Parmers or Addition of
Spouse where new fingerprint cards are required(see New Application Requirement Guide).
• 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.
Please complete information on the following pages for EACH person fingerprinted.
FORM 147
REV OCT 2015
PAGE 1
Rt.
e 3 203
L Name: (Please print legibly) NEBRASKA LIQUOR
Date of Birth: Last 4 SSN: Oft
How was payment made to NSP? ONSP PAYPORT Or
2. Name: (PTease print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? ONSP PAYPORT Or OCHECK SENT TO NSF Ck#
3. Name: (Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF*? ONSP PAYPORT Or OCHECK SENT TO NSF Ck#
4. Name: (Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? DNSP PAYPORT Or OCHECK SENT TO NSF Ck#
5. Name: (Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF*? ONSP PAYPORT Or OCHECK SENT TO NSF Ck#
6. Name:
(Please print legibly)
Date of Birth: Last 4 SSN:
How was payment made to NSF? ONSP PAYPORT Or OCHECK SENT TO NSF Ck#
l 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): Title:
Si nature: Date:
FORM 147
REV MAR 2015
PAGE 2
. .
.__Point7of-Sale Payments Page 1 of 2
A 0 II
NF BR ASKA (;0\'
YOUR RECEIPT ...
Nebraska State patrol-Criminal Identification Division
3800 NW 12th Street,Suite A
Lincoln NE 68521
(402)479-4971
Transaction Id: 7975362 NFBRASKA LIQUOR
THANK YOU FOR USING THE NEBRASKA STATE PATROL PAYPORT SERVICE CONTROL COMMISSiON
Customer Name: Lonnie G Eggers
Credit Card Number: **** **** ** *
nebraska total amount charged $29.47
Total
Items Location Quantity Order ID Amount
Liquor License 1 17989502 $28.75
Applicant Name; Lonnie Eggers
Date of Birth:
Last four digits Soc. Security Number:
Total remitted to the Nebraska State Patrol- Criminal Identification Division $28.75
\
https://otc.cdc.nicusa.com/PublicReceipt.aspx?src=esh
11/16/2015
City of Omaha, //,
.... ._.,NF 1819 Farnam —Suite LC 1 �`J :A
ka 68183-0112(402) 444-5550 n7 W-I� ;u 7
Omaha, Nebras o�'': � °<
0 �^
Buster Brown FAX (402) 444-5263
City Clerk �RTFD FEBOA
December 7, 2015
Hinky Dinky Leavenworth,LLC Application to appoint Lonnie G. Eggers
Dba"Nuestra Familia Supermercado #733" manager of your present Class"C" Liquor
2900 Leavenworth Street
License location
Omaha,NE 68105
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City tuber Council
on
your
application
The City
appoint a manager to the liquor license has been set for De Omaha/Douglas Civic
LC-4 ,
Council Meeting begins at 2:00 P.M. in the Legislative Chamber, ( "EachCenter, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states,
applicant or his/her representative for any type of license
ne shall be a of public hearing
ly present in the
Council Chambers, in order that the Council may makeinquiries, on the date
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,
/1 44
Buster Brown
City Clerk
BJB:clj
014p,HA, NF
4,
City ofOmaFui, 7 .r p._
Nab-
1819 Farnam — Suite LC 1 �® i,�,^ I r.
Omaha, Nebraska 68183-0112 0 r '
(402) 444-5550 �•� - �,
Buster Brown FAX (402) 444-5263
•
City Cler
k 0�9�ED FE9RU •k.
December 7, 2015
Lonnie G. Eggers Application to be appointed manager of the
2404 South 182nd Circle present Class "C" Liquor License locations
for Hinky Dinky Leavenworth, LLC and U
Omaha,NE 68130 Save Foods, Inc. — SEE ATTACHED LIST
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council o22 your
application
plicationTh tCbe
appointed manager of the liquor license has been set for Decem
Civiclas
y
Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas
Center, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states,
applicant or his/her representative for any type of license shall be personally present in the
Council Chambers, in order that the Council may makeinquiries,
Counc 1 Meeting ispublic
ounds to
hearing
of the application for said license". Failure to be present at this
recommend denial of your application to the Nebraska Liquor Control Commission.
Sincerely yours,
AtOze:
Buster Brown
City Clerk
BJB:clj
HINKY DINKY LEAVENWORTH, LLC 2900 LEAVENWORTH STREET
68105
DBA NUESTRA FAMILIA SUPERMERCADO#733
U SAVE FOODS, INC
5110 SOUTH 108TH STREET 68137
DBA BAG N SAVE#774
U SAVE FOODS, INC
2650 NORTH 90TH STREET 68114
DBA BAG N SAVE#780
U SAVE FOODS, INC
15370 WEIR STREET 68106
DBA BAG N SAVE#781
U SAVE FOODS, INC
14444 WEST CENTER ROAD 68137
DBA BAG N SAVE#784
U SAVE FOODS, INC 3003 NORTH 108TH STREET
68154
DBA BAG N SAVE#785
U SAVE FOODS, INC
5019 GROVER STREET 68108
DBA FAMILY FARE#779
U SAVE FOODS, INC
820 N SADDLE CREEK ROAD 68107
DBA FAMILY FARE#797
U SAVE FOODS, INC
8005 BLONDO STREET 68144
DBA NO FRILLS SUPERMARKET#789
U SAVE FOODS, INC
3548"Q" STREET 68164
DBA NO FRILLS SUPERMARKET#793
U SAVE FOODS, INC
7402 NORTH 30TH STREET 68134
DBA NO FRILLS SUPERMARKET#795
U SAVE FOODS, INC
3026 SOUTH 24TH STREET 68112
DBA NO FRILLS SUPERMARKET#800
U SAVE FOODS, INC
1826 VINTON STREET 68108
DBA NUESTRA FAMILIA SUPERMERCADO#775
No. / (17
Hinky Dinky Leavenworth, LLC, dba "Nuestra
Familia Supermercado #733, 2900
Leavenworth Street, requests permission to
appoint Lonnie G. Eggers manager of their
present Class "C" Liquor License location.
12-22-15;cj
RECEIVED
Presented to Council:
December 22, 2015 - Approved 7 -O
Buster Brown
City Clerk