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RES 2015-0824 - Appoint Danielle R Campbell manager of Walmart Store 3152 � r — r ^ U [� D [\ � i � | V [. 0 STATE <]F /��� EBRASKA 7 Pete Ricketts NEBRASKA LiQuoR CONTROL COMMISSION Hobert B. Rupe a�e "u",m�r�, CFY CLERK 301 CentetinialMall SCUth,5th Floor P.O. mmvsn*a O H " ' NE 8 RA S K Lincoln.Nebraska sosop so«s Phone(4Oc)«71'es7z Fax(4O2)471'u314m(14*z)471'o37o TRs USER 000a3x'7s5c[rry %A:vbuuume. June Z2, 2OI5 DMAHA CITY CLERK 1819 FARNAK4 STREET LC-1 {}K4AHANE68l83 RE: Manager Application Danielle R. Campbell | Ll[ENSE #D'IO5O88 � Dear Clerk: Enclosed is a copy of manager application for Danielle R. Campbell, in connection with theVVa|rnart Store3lS3' located in Omaha. Please present this application for manager to your City/Village Council or County Commissioners and send us the results of their action. Sincerely, y Jacqueline Rodriguez Licensing Division NEBRA6KA LIQUOR CONTROL COMMISSION 402-471-2571 end. Janic°w.Wiebu"m Robert Batt Bruce Bailey o=...-=, c."~^°""~ x"e,"o,cpn ,',"^ra"'�*, 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 <e E t Website:www,lcc,ne,gov MUST BE: ✓ Citizen of the United States. Include cony of US birth certificate,naturalization paper or current US passport ✓ Nebraska resident. Include cony of voter registration in the State of Nebraska V. Fingerprinted. See Form 147 for further information,this form MUST be included with your application. ✓ 21 years of age or older Name of Corporation/LLC: LJplrnw'LT S1-o1R S rlC. Liquor License Number: 1.OSO 2 Class Type (if new application leave blank) Premise Trade Name/DBA: t„}( (AN1-2-...i . 3l SZ Premise Street Address: 2 LI S1 rJ C STR£ 'r- City: QwlA N'A County: T C,LAS Zip Code: 6cs' 3`i Premise Phone Number: --49-a- 41 l - 2 $ - 21 4 Email address: A.Ni©p iJ. 7a t,Szo 0 t..►p t.MA I LT cc v\ 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. http:/ c.ne.eov/license sear /licsearch.cei SIGNATURE Q D B ORPORATE OFFICER/MANAGING MEMBER ( d signatures are acceptable) Form 103 REV JAN 2015 1500014343 Page 2 of 6 Manager's information must be completed below Pl:AASEPRI.,„N.T,,afAttly Last Name: tY1 t First Name: t)ilm ctic NIL Home Address(include PO Box if applicable): I Li' ‘73t C ( A-vf, City: k.,,1 /1, County: 1)C) Zip Code: U ? I I Home Phone Number: 1) 50 Business Phone Number: (if()) ) 4 62, 0 Ne. Social Security Number: 'Drivers License Number& State: Date Of Birth: . „ — Place Of Birth: 10 C C C.‘ N Email address: d ittte, C (1'1 C C„. ‘Y.70 e WI rn Are you married?If yes, te spouses information(Eveh'if'a:41:4141.f04:eiti:W-5'ilieib*.iti"e:a): YES LINO Spouse's information Spouses Last Name: Cel VYt C tk First Name: 11. 1/ MI: Social Security Security Number , _ _ _ Drivers License Number& State:IV Date Of Birth: Place Of Birth: Ant1)6 fl C ty, A APPLICANT 8i SPOUSEol'''-''!.'bi'a- ,ftL_:.:-iir',N-M$)ttir;fit::t4irrtit:E'.*.'Ococccrkivtj'' ,sect,,z;t2i k=2,37, YEAR YEAR YEAR YEAR CITY & STATE CITY & STATE FROM TO FROM TO it / )iN (1, 1-11 I I - Cili- L./04f IA ie,c. '2,0c1 AIFIT)RASKA 1,-,17.WOR ecafkim;:3t3i0i-,1 Form 103 REV JAN 2015 Page 3(31'6 MANAGER'S LAST TWO E PIOYES YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER tbi2- V\itil I WI i/ LA A et\I fv'.0:0 I/ 1 t T its ( 1 /3 L-bitAhc-oc-fi 1)Lkn ) ;-!) 1 I. 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 anv 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. r YES 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 P C C At!iSSiO 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? LJYES rtiNO IF YES, list the name of the premise(s): 3. Do you, as a manager, qualify under Nebraska Liquor Control Act (§53-13 1.01) and do you intend to supervise, in person,the management of the business? 'YES F1N0 Form 103 REV JAN 2015 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: Name on Certificate: Applicant Name ( Datemm/YYYY) Name of program(attach copy of course completion certificate) *For list of NLCC Certified Training Programs see wwv,icc.ne..gov/traininainfoluml Experience: Applicant Name/Job T Date ofitle Name&Location of Business: Employment: 1 „- kof 5. Have you enclosed Form 147 regarding fingerprints? )thYES F7NO Form 103 REV JAN 2015 Page 5 of 6 PERSONAL OATH AND CONSENT OFVESTWATION: 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 §5 3-131.01)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 fraudu lent. ,. / f( f 'r r'-4 ` , _ " Signature o Manager_Applicant Signature of Spoids L,`( i l S I;i ti,, ACKNOWLEDGEMENT State of Nebr ska County of ikt 47 The foregoing instrument was acknowledged before me this t by ! {hv1 S 1 1f1- L.-oL t 1'1 1 1 ( date name of person acknowledged /7 /1"..,,,,,,,,..--- ( f Affix Seal Notary Public signature JOHN F BLACK General Notary State of Nebraska Ion )(pires Dec 9,2017 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 JAN 2015 Page 6 of 6 Print Form SPOUSAL AFFIDAVIT OF Office Use NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOU"I II PO BOX 95046 LINCOLN,NE 68509-5046 4,, PHONE (402)4 71-2571 FAX.(402)471-2514 Website kk-,,e k"e,u I acknowledge that I am the spouse of a liquor license holder. My signature below.conftrms that I will have not have any interest,directly or indirectly in the operation or profit of the business:(§53-125(13))of theL quor 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 applicationsapplications,,needed to process this application. '---:‘, Ili ' / ----7-,,fe.A...\-4. ('P' Signat re of spou e asking for waiver Print name of spouse asking for waiver (S oue of individual listed below) ) State of 1\\\ 6,P AS kt\ i County of tl The foregoing instrument was acknowledged before me this Le/eV 7,-c i s-- by r1 r-c 11 t (ct v"tf 1`d q. date name of person acknowledged ? Allis Seal r---- r'1 " -"� r f*' / 1 "' NATHAN J MCLAUGHLIN C Nota � Public signature .II S';a+_ of Ntti,;)sk.g.Ge�P:a'.Notary „ My Ctinomi mqn Expires July 30, 2018 1 acknowledge that I am the spouse of the above listed individual I understand that my spouse and"I are responsible for compliance with the conditions set out above. If it is determined that the above individual has violated(§53-`125(13))the Commission may cancel or revoke `iquor license. , 1 ) 2 ' c . '� ((.1�"�1 - ^ / 1 � C al p1�=�-(-) 11 Signature of4ndivid 1'fnv ".h application Printed name of applying individual (spouse of individual listed above) State of 4't., A& I<c`\. County of U f' Ck lc( 5 The foregoing instrument was acknowledged before me this 6; " 3-1 S by l..JG vI C ( e__ atol 0 I l �dale, 7 name of person acknowledged !-1 11:7 f ''-' /7 t -. (/' lr/7` fl7, -- -- Affix Seal qb, — — AM, � w f Nottjr4 Public signature JOHN F BLACK M 0 General Notary 1 1 State of Nebraska 1 l' My Commission Expires Dec 9,ZU1/ In compliance txtth the ADA,this spousal affidavit of non participation is available in other formats for perso. ' • • • A ten day advance period is requested in writing to produce the alternate format. FORM 35-4 I78 Revised 1/2008 p�1AI-Irl, tV Citg ofOmaha, \[ebrasg , 1819 Farnam —Suite LC 1 Omaha, Nebraska 681 83-01 1 2 Srh r4: '-19 '^ Buster Brown (402) 444-5550 City Clerk FAX (402) 444-5263 o 4� 9T�D FEWO' June 30, 2015 Wal-Mart Stores, Inc. Application to appoint Danielle R. Campbell Dba"Walmart Store 3152" manager of your present Package Liquor 2451 North 90th Street License location Omaha,NE 68134 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 July 14, 2015 . 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, 46L601 Buster Brown City Clerk BJB:clj CiCity of OmaFta 9Vebrasfaalrifrkri o�oMAHA, N�8 1819 Farnam — Suite LC 1 Omaha, Nebraska 681 83-01 1 2 vz r rhoBuster Brown (402) 444-5550 ,o ,_-- City Clerk FAX (402) 444-5263 �41) 9TFD FE130 - June 30, 2015 Danielle R. Campbell Applications to be appointed manager of the 16532 Butler Avenue present Package Liquor License location for Omaha,NE 68116 Wal-Mart Stores, Inc., dba"Walmart Store 3152", 2451 North 90t' 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 July 14, 2015 . 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, 44 ,400,dAt224. Buster Brown City Clerk BJB:clj No. 8Z-4 Wal-Mart Stores, Inc., dba "Walmart Store 3152", 2451 North 90th Street, requests permission to appoint Danielle R. Campbell manager of their present Package Liquor License location. 07-14-15;cj RECEIVED Presented to Council: July 14, 2015 -Approved 7-0 Buster Brown City Clerk