LA VISTA POLICE DEPARTMENT INTER-DEPARTMENT MEMO LOCAL BACKGROUND- LIQUOR LICENSE- MANAGER-AVP ENERGY L.L.C. DBA SINCLAIR GAS STATION

Transcription

1 A-13 LA VISTA POLICE DEPARTMENT INTER-DEPARTMENT MEMO TO: FROM: DATE: RE: CC: Pam Buethe, City Clerk Chief Robert S Lausten September 29, 2014 LOCAL BACKGROUND- LIQUOR LICENSE- MANAGER-AVP ENERGY LLC DBA SINCLAIR GAS STATION The police department conducted a check of computerized records regarding the applicant for the Manager application, Kevin Matras (AVP ENERGY LLC, OBA SINCLAIR GAS STATION) Matras has no criminal record in Nebraska

2 September 24, 2014 Dave Heineman Governor STATE OF NEBRASKA NEBRASKA LIQUOR CONTROL COMMISSION Hobert B Rupe Executive Director 301 Centennial Mall South, 5th Floor PO Box Lincoln, Nebraska Phone (402) Fax (402) or (402) TRS USER (TIY) web address: LA VISTA CITY CLERK 8116 PARK VIEW BLVD LA VISTA NE RE: Manager Application Kevin Matras LICENSE B Dear Clerk: Enclosed is a copy of a manager application for Kevin Matras in connection with the AVP Energy #5 located in La Vista Please present this application for manager to your City/Village Council or County Commissioners and send us the results of their action Sincerely, Jacqueline Rodriguez Licensing Division NEBRASKA LIQUOR CONTROL COMMISSION encl Janice M Wiebusch Commissioner Robert Batt Chairman William F Austin Commissioner An Equal Opportunity Employer Printed \vith soy ink on rec icled paper

3 MANAGER APPLICATION INSERT - FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION 30 I CENTENNIAL MALL SOUTH PO BOX LINCOLN, NE PHONE: (402) FAX: (402) Website: wwwlccnegov Office Use RECEIVED SEP NEBRASKA LIQUOR CONTROL COMMISSION 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 in the State of Nebraska / Fingerprinted Two cards per person, fees of $38 per person, made payable to Nebraska State Patrol If printed at NSP mail check only / 21 years of age or older Liquor License Number: / Premise Trade Name/DBA: (if new application leave blank) AVP Energy #5 I AVP Energy #3 Class Type_B_/_D Premise Street Address: 8307 Parkview Blvd / Pacific St City: La Vi sta/ Omaha County: Sarpy/ Douglas Zip Code: 68128/68114 Premise Phone Number: / address: Shendrix@aVpenergycom 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 cense search/licsearchcgi /)1, SllGNA'l'::liIRED BYllil 'J'@R'A:TitOFFIGER inianm}tng' EMBf:R (Faxed signatures are acceptable) i Form 103 Page 2 of6

4 Last Name: Matras Home Address (include PO Box if applicable): First Name: Kevin 8540 Granville pkwy Apt# 919 City: Lavista County: Sarpy Zip Code: Home Phone Number: Business Phone Number: - Social Security Number: Date Of Birth: 01/15/1986 Em a i I address: Kmatras@yahoocom Ml: p -- H NE Drivers License Number & State: Kearney NE Place Of Birth: DYES Ii] NO Spouses Last Name: First Name: Ml: Social Security Number: Drivers License Number & State: Date Of Birth: Place Of Birth: CITY & STATE FROM Lavista NE 2011 TO Present CITY & STATE FROM TO Papillion NE ronn I 03 Page J of 6

5 NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER May 2014 Present AVP Energy Sandy Wetzel First Data Mat READ CAREFULLY ANSWER COMPLETELY AND ACCURATELY Must be completed by both applicant and spouse, unless spouse has filed an affidavit of nonparticipation Has anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge Charge means fil!y 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 t e 1 \ ""tilth of the conviction or plea Also list any charges pending at the time of this application If m 1 &t'(,cfrcy:'please list charges by each individual's name D YES NO If yes, please explain below or attach a separate page Date of Where Name of Applicant Conviction Convicted (mm/yyyy) ( City & State) SEP 12 20\4 NEBRASKA - L\QUOR _- --r I f"()tji MlSS\0 Descrtf!Mh" 1 - ', of Charge Disposition 'J, 2 Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? DYES [i]no IF YES, list the name of the premise(s): 3 Do you, as a manager, qualify under Nebraska Liquor Control Act ( I) and do you intend to supervise, in person, the management of the business? li]yes ONO Fonn 103 Page 4 of 6

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 Date (mm/ Name of program (attach copy of course completion certificate) D *For list ofnlcc Certified Training Programs see wwwlccne!>:ov/traininginfohtml E xpenence: Applicant Name/ Job Title Date of Employment: Name & Location of Business: Kevin Matras Assistant Manager May 2014 Avp Energy 8307 Parkview Blvd Lavista Ne Have you enclosed the required fingerprint cards and PROPER FEES with this application? (Check or money order made payable to the Nebraska State Patrol for $3800 per person) [i]yes ONO Forni 103 Page 5 of6

7 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 I) 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, RECE\VEO State of NCbraska County o ACKNOWLEDGEMENT Signature o(spouse SEP NEBRASKA uauor CONTROL comm\sston The foregoing instrument was acknowledged before me this # ±\ l;l - { ;\'1%} -- O f- d,e - -- by v fkl0i! Q ged Affix Seal :lll--,- -E-N-ERA_L_N -:-: OT AR Y :- _ :-:-Sta :- te-o '"" f N :-: e:i-ra '":" sl< 1 a NANCY M JOBEL My Comm Exp December 11, 2015 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 Fonn 103 Page 6 of6

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9 -u va,;uf,w14 3:23 PM Printed: 08/27/2014 3:23 PM Registrant Search Results Sarpy Registrant ID Status Registrant Name Address Precinct Part Birth Date Registration Date Phone Party Gender Race Active Matras, Kevin Paul Apt Granville Pkwy la Vista, NE /1986 1/ Republican Male Total for Sarpy: Total number of Registrants: 1 l --- -=,:,' = = 0::::;:--:---l-:;------:----, _ i;mi tti :::f' p hrst Luthe!lll) Church 40 4W N Washington St Papillion L'S CO!J!!fCSSionaJ District > County te,tslah, c o;slrict14 - Coiumissi oncr o Ma "Of of istncr Pa 2 11illion Pap!lhon City jj Papdl1on-La Ward 4 v,sra Leammg Public Sch Cotnmunity l - Disr > : arp),',oµnty; State ofn braska, ' S C ' : I Paul K Matras 314 S Polk St Papillion, NE rt Design Copyright e 2014 Election Systems and Software, Inc Page 1 of 1