2010-074 - sarpy county, nebraska · 1210 golden gate dr ste 1129 papillion ne 68046 renew not...
TRANSCRIPT
BOARD OF COMMISSIONERS SARPY COUNTY, NEBRASKA
2010-074
RESOLUTION AUTHORIZING CHAIRMAN TO SIGN FORM SOG COUNTY/CITY LOTTERY LICENSE RENEWAL APPLICATION, FORM SOG-l COUNTY/CITY
LOTTERY OPERATOR (SCHEDULE J) LICENSE RENEWAL APPLICATION AND FORMS SOG-II COUNTY/CITY LOTTERY SALES OUTLET (SCHEDULE II)
LICENSE APPLICATIONS
WHEREAS, pursuant to Neb. Rev. Stat. §23- \04(6)(Reissue 1997), the County has the power to do all acts in relation to the concerns ofthe County necessary to the exercise of its corporate powers; and,
WHEREAS, pursuant to Neb. Rev. Stat.§23-I03(Reissue 1997), the powers of the County as a body are exercised by the County Board; and,
WHEREAS, the Nebraska Department of Revenue requires Sarpy County to submit a Form SOG for the renewal of Sarpy County's Keno license; and,
WHEREAS, the Nebraska Department of Revenue requires Sarpy County to submit a Form 50G-I for the renewal of the Lottery Operator License; and,
WHEREAS, Advanced Gaming Technologies, Inc. is the current Lottery Operator for Sarpy County; and,
WHEREAS, the Nebraska Department of Revenue requires Sarpy County to submit Form 50G-II for the renewal and non-renewal of Lottery Sales Outlet licenses for lottery outlets in Sarpy County; and,
WHEREAS, M Martian LLC (On the Rocks Lounge), LaPlatte Enterprises, Inc. (Lodge), High Spirits, Inc. (Waterfall Lounge), GAM Enterprises LLC (Americana Bistro), Catfish Lake and Depot, Inc. (Rum Runner) operate keno lottery outlets in Sarpy County; and,
WHEREAS, International Hospitality, Inc. (Ramada Limited) is no longer a keno lottery outlet in Sarpy County.
NOW, THEREFORE, BE IT RESOLVED, By the Sarpy County Board of Commissioners, that the Chairman of such Board is hereby authorized to sign the following attached forms
I. Form 50G County/City Lottery Sales Outlet Location Application to renew Sarpy County's Keno License.
2. Form 50G-1 County/City Lottery Operator Application to renew Advanced Gaming Technologies, Inc. Lottery Operator license.
3. Form SOG-II County/City Lottery Sales Outlet Applications to renew Sarpy County Keno outlet licenses for M Martian LLC (On the Rocks Lounge), LaPlatte Enterprises, Inc. (Lodge), High Spirits, Inc. (Waterfall Lounge), GAM Enterprises LLC (Americana Bistro), Catfish Lake and Depot, Inc. (Rum Runner) .
4. Form SOG-II County/City Lottery Sales Outlet Application not to renew International Hospitality (Ramada Limited).
~VED by --r;;.,. ~ , seconded by U~ 1fJ2.e , that the above Resolution be adopted. Carried.
DATED and approved this ll.ll-"dayof WlliUb ,2010.
NAYS: ABSENT:
~ ABSTAIN:
-~ Nebraska Department of
REVENUE Nebraska Department of Revenue
County/City Lottery License Renewal Application for 2010-2012
LOCATION NAME/ADDRESS
COUNTY OF SARPY 1210 GOLDEN GATE DR PAPILLION NE 68046
STATE I. D. 35-000806323 FED 1.0. 476006504
County/City Lottery ($100 license fee)
Please provide the following information:
METHOD OF WINNING NUMBER SELECTION
D Manual Ball Draw
IX] Automated Ball Draw
D Random Number Generator
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS COUNTY OF SARPY ATTN DEBBY PEOPLES
. 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046
Renew Not Renewing [X] D
D Both Automated or Manual Ball Draw and RNG
(If both, attach schedule showing days and times each method will be used)
PRIMARY COUNTY, CITY, OR VILLAGE REPRESENTATIVE (Make changes. if necessary)
Form SOG
Name, Address, City, State, Zip Code
HANSON/BRIAN E
Title
COUNTY FISCAL ADMINISTI
Daytime Telephone Number
(402) 593-2349 COUNTY OF SARPY COURTHOUSE 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046 E-mail [email protected]. VoN)
AUTHORIZED REPRESENTATIVE(S) FOR LOTTERY WORKER LICENSE APPLICATIONS (Make changes, if necessary)
Name, Address, City, State, Zip Code
HASSETT/KYLE CAROLINE ADVANCED GAMING TECHNOLOGIES INC 3915 HARRISON ST BELLEVUE NE 68147
HOWARD/MICHELLE ADVANCED GAMING TECHNOLOGIES INC 3915 HARRISON ST BELLEVUE NE 68147
Title Daytime Telephone Number
AUTHORIZED REPRESENTATIVE
E-mail __________________ _
AUTHORIZED REPRESENTATIVE
Form SOG - County/City Lottery License Renewal (continuation page)
COUNTY/CITY COUNTY OF SARPY STATE I.D. 35-000806323
AUTHORIZED REPRESENTATIVE(S) FOR LOTTERY WORKER LI CENSE APPLI CAnONS (Make changes if necessary)
Name, Address, City State, Zip Code
HASSETT/JOHN DANIEL ADVANCED GAMING TECHNOLOGIES INC 3915 HARRISON ST BELLEVUE NE 68147
PEOPLES/DEBORAH L SARPY COUNTY COURTHOUSE 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046
Title
AUTHORIZED REPRESENTATIVE
GOVERNING OFFICIAL
Daytime Telephone Number
(402) 618-0038
(402) 593-4164
E-mail o...ebp ~ ZP-rPj . Cora
Under pena~ies of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I will comply with the provisions of the Nebraska County and City Lottery Act and the regulations adopted under such Act.
Signature of Governing Official
Mail application and fee to:
Title Oate baYfme leJephone Nuri£er
NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
_/L----z.--Nebraska Departmenl of
REVENUE Nebraska Department of Revenue County/City Lottery Operator (Schedule I)
License Renewal Application for 2010·2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE I.D. 35·000806323
LOCATION NAME/ADDRESS ADVANCED GAMING TECHNOLOGIES INC ADVANCED GAMING TECHNOLOGIES 10308 S 23RD ST BELLEVUE NE 68123
OPERATOR STATE I.D. 35·009258752
OPERATOR FED I.D. or SSN 200574210
Lottery Operator License ($500 license fee)
Owners, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS ADVANCED GAMING TECHNOLOGIES INC 10308 S 23RD ST BELLEVUE NE 68123
Renew Not Renewing [ZJ D
Form SOG-I
Please make any necessary corrections to the information listed below and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying for the license, this license renewal application may not be used. A separate Nebraska Schedule I - County/City Lottery Operator App6cation, Form saG. must be completed in its entirety and filed with the Charitable Gaming Division. Please contact the Charitable Gaming Division to obtain a Form 500, Schedule I, orvisit our Web site at WYNI.revenue.ne.govJgaming.
SSN/STATE I.D. NAME/ADDRESS
MONASTERO/JOSEPH ANTHONY 709 PINE ST OMAHA NE 68108
MONASTERO/CONNIE M 709 PINE ST OMAHA NE 68108
HASSETT/JOHN DANIEL 3211 S 57TH CIR OMAHA NE 68106
KRUSE/RODNEY G 8129 FRANCES ST OMAHA NE 68124
KRUSE/MARIL YN K 8129 FRANCES ST OMAHA NE 68124
TITLE STOCKHOLDER
SPOUSE
PRESIDENT
SPOUSE
% OWN 12.50
41.00
12.50
Form SOG (Schedule I) - County/City Lottery Operator License Renewal (continuation page)
COUNTY/CITY COUNTY OF SARPY OPERATOR STATE 1.0. 35·009258752
SSN/STATE 1.0. NAME/ADDRESS TITLE SPOUSE
HASSETT/ALBERTA MARY ANN 3211 S 57TH CIR OMAHA NE 68106
HODGES/NANCY ANN 7728 S 70TH ST OMAHA NE 68128
STOCKHOLDER
E-mail Nr:;.. AoJSd f(l-@ CDc- . .vet-DOBELIMICHAEL THOMAS SECITREAS 1723 S 155TH AVE OMAHA NE 68144
E-mail f).l;[email protected] .. 1.~IVJ.Co.....-DOBELISUSAN ELIZABETH SPOUSE 1723 S 155TH AVE OMAHA NE 68144
ODORISIO/MICHAEL D 7401 S 140TH AVE OMAHA NE 68138
E-mail c.. 04d{ O~'f t2 a 0 I . UnA..
ODORISIO/MARGARET 7401 S 140TH AVE OMAHA NE 68138
STOCKHOLDER
SPOUSE
IIMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
% OWN
12.50
12.50
9.00
Since April 1, 2008, have any of the individuals listed above been convicted of, forfeited bond upon a dlarge of, or pled guilty or nolo contendere to any felony or misderreanor involving fraud, theft. any gambling activity, wDlful faHure to make required paymmts or reports, or filing false reports with a governmental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
['fJ NO [] YES If YES, please refer to the instructions forthe information to be provided.
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, H is correct and complete. I will comply wHh the provisions of the Nebraska County and City Lottery Act and the regulations adopted under
su~t. ( , ~~ o<l~ Qr-es,<-L± 1,-j_lo 402.-\ W 1f"-o03k sIQUieOoWilerjartner,er, or Title Date aytme Telephone Nul'T&r om er of Lottery Op~ator
I dij?1CI t at I h~vb examined this application, and authorize the applicant to conduct the countylcHy lottery on behalf of the co . y, or ~iliage named in this application.
l Vice. Chc('(I'I\4y\ 3-1\0-10 ~~t 5~~-~'5" Signature of Go (,;ing Official Title Date Da e elephone Nurrber
Ma~ application and fee to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN. NE 68509-4855 (Please make a copv for vour records)
-~ Nebraska Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS M MARTIAN LLC ON THE ROCKS LOUNGE 16919 AUDREY ST STE 100 OMAHA NE 68136
SALES OUTLET STATE 1.0. 35-009358307
SALES OUTLET FED 1.0. or SSN 861104053
LIQUOR LICENSE NUMBER 64538
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) D Keno Satellite g Keno Independent Game
Ow.re;:-s, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS M MARTIAN LLC 16919 AUDREY ST STE 100 OMAHA NE 68136
Renew
pQ Not Renewing
D
Form 50G-1I
Please rmke any necessary corredions to the information listed below and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying for the license, this license renewal app6cation may not be used. A separate Nebraska Schedule II - County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form 5OG, Schedule II, or visit our Web site at WYNI.revenue.ne.govlgaming
SSN/STATE 1.0. NAME/ADDRESS NATSTAR PARTNERSHIP 16919 AUDREY ST STE 100 OMAHA NE 68136
HOUSTON/JOHN W 5106 S 181ST PLZ OMAHA NE 68135
LENGEMANN/JACK GERARD 10522 MONROE ST OMAHA NE 68127
HOUSTON/SARAH VIRGINIA 5106 S 181ST PLZ OMAHA NE 68135
HOUSTON/BRIAN MICHAEL 16428 OLIVE ST OMAHA NE 68136
TITLE MEMBER
GENERAL PARTNER
GENERAL PARTNER
SPOUSE
MEMBER
% OWN 90.00
10.00
Form 50G (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE 1.0. 35-009358307
SSN/STATE 1.0. NAME/ADDRESS
LENGEMANN/JEANETTE A 10522 MONROE ST OMAHA NE 68127
TITLE SPOUSE
IIMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
% OWN
Since Apri11, 2008, have any of the individuals listed above been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity, wiUful faikJre to make requi-ed payments or reports, or filing false reports with a governmental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
[ ] NO [] YES If YES, please refer to the instructions forthe information to be provided.
Under penalties of law. I declare that I have examined this application. and to the best of my knowledge and belief, it is correct and complete. I ~iII comply with the provisions of the Nebraska County and City Lottery Act and the regulations adopted under such
19" re 0 er, a ner, er, or ~.
Date I Officer of Sales Outlet Location
I declare that I hav~)examined this application, and authorize the applicant to conduct the county/city lottery on behalf of the county, . , r "Wage named in this application.
Vice c..Mo;mal\ 3 -!le- iO Lfoz. - 5'i3-~\gs-Signature of ~vernjng Official Title Date ba}lfme Telephone NuiTber
U' Mail application to: NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
(Please make a copy for your records)
1IIl.~ Nebraska Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS LA PLATTE ENTERPRISES INC LODGE 16609 CLAY ST LAPLATTE NE 68123
SALES OUTLET STATE I.D. 35-006776175
SALES OUTLET FED I.D. or SSN 470762966
LIQUOR LICENSE NUMBER 25210
Sales Outlet Location License (No license fee)
Tvpe of Location (Check onel I4J Keno Satellite !SD Keno Independent Game
Owners, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS LA PLATTE ENTERPRISES INC 16609 CLAY ST LAPLATTE NE 68123
R~~,~ Not Renewing
D
Form SOG-II
Please rrake any necessary corredions to the information listed below and complete any missing information. If there has been a dlange of ownership in the business resulting in a different legal entity applying for the license, this license renewal appUcation may not be used. A separate Nebraska Schedule II - County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form 5OG, Schedule II, or visit our Web site at WWN.revenue.ne.gov/gaming
SSN/STATE I.D. NAME/ADDRESS
KRAJICEK/EDWARD L JR 2807 LAPLATTE RD OMAHA NE 68123
STRAZDAS/CAROL A 1511 CEMETERY RD BELLEVUE NE 68123
TITLE VICE PRES/SEC
CEO/PRESITREAS
% OWN 50.00
50.00
Form 50G (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE I.D. 35-006776175
SSN/STATE I.D. NAME/ADDRESS TITLE % OWN
jlMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
Since April 1. 2008, have any of the individuals listed above been convicted of, forfeited bond upon a charge of, or pled guitty or nolo contendere to any felony or misdemeanor involving fraud, theft, any gambling activity, wiDful fai .... re to make required payments or reports, or filing false reports with a grernmental agency at any level (this indudes shopHfting or issuing bad checks), OR to any other felony other than those listed above?
[~NO [] YES If YES, please referto the instructions forthe information to be provided.
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, ~ is correct and complete. I will comply ~h the provisions ofthe Nebraska County and C~y Lottery Act and the regulations adopted under such Act.
19" ure Yvner, an. er, or Title ~-3-/0
ate Officer of Sales Outlet L
I declare that I have examined this application, and authorize the applicant to conduct the county/c~ lottery on behalf of the county, 'it, dr village named in this application.
I TillY \ Ce., Ch..jr iWLV\ D~;I (. -I 0 Dait~ I-el@~n: N~J£S-
NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
• ..,./L.-----z..-NBbras~iI Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS HIGH SPIRITS INC WATERFALL LOUNGE 10208 S 168TH AVE STE A & B OMAHA NE 68136
SALES OUTLET STATE LD_ 35-009834036
SALES OUTLET FED 1.0. or SSN 204362411
LIQUOR LICENSE NUMBER 72195
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) o Keno Satellite
~Keno Independent Game Owners, Partners, Members, and Corporate Officers:
PLEASE DD NDT WRITE IN THIS SPACE
MAILING NAME/ADDRESS HIGH SPIRITS INC 10208 S 168TH AVE STE A & B OMAHA NE 68136
Renew
)& Not Renewing
D
Form SOG-II
Please rmke any necessary corrections to the information listed below and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entrty applying for the license. this license renewal appHcation may not be used. A separate Nebraska Schedule II - County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form SOG, Schedule II, or visit eb site at WWN.revenue.ne.gov/gaming
SSN/STATE 1.0. NAME/ADDRESS BARGSTADT/JOHN L
11078 LAKE RIDGE DR OMAHA NE 68136
BARGSTADT/LORI S 11078 LAKE RIDGE DR OMAHA NE 68136
ITLE PRESIDENT
SECNlCE PRES
% OWN 50.00
50.00
Form SOG (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE I.D. 35-009834036
SSN/STATE I.D. NAME/ADDRESS TITLE % OWN
IIMPORTANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
Since April1, 2008, have any of the individuals listed above been convicted of, forfeited bond upon a charge of, or pled guitty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity, wiUful faiure to make requred payments or reports, orfiling false reports with a governmental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
)< ..P4 NO [] YES If YES, please refer to the instructions forthe information to be provtded.
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I will co ply with he provisions of the Nebraska County and City Lottery Act and the regulations adopted under
n ure 0 wner, a ner, Officer of Sales Outlet Locatio
jfe:JJe~f ~-S--(O C:;O:<' t6/--/61/-)/0f1'£ "'Ti:7.II;C.'-""-'-::..:.:::....:----- nD"'al;;:.--"---- uaYlme Ielephone Nuri'ber
,/02 991 - 800 ( - fyJ" I declar at ,I have examined this application, and authorize the applicant to conduct the county/city lottery on behalf of the cou I ci ,or village named in this application.
, ~ \J;c..e.. C.\I\wrMM\ 3-\10-10 LfOl- 9i~ -41S-S-Sig atureo Governing Official Title Date DaYfrne lelephoneNuriber
I Mail applicalion 10: NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
(Please make a copy for your records)
.,.~
Nobras~a Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS GAM ENTERPRISES LLC AMERICANA BISTRO 2403 TREGARON TOWNE CTR STE 200 BELLEVUE NE 68123
SALES OUTLET STATE 1.0_ 35-010276025
SALES OUTLET FED 1.0_ or SSN 262162019
LIQUOR [ICENSE NUMBER 80491
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) o Keno Satellite
S/ Keno Independent Game
Ow ers, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS GAM ENTERPRISES LLC 2403 TREGARON TOWNE CTR STE 200 BELLEVUE NE 68123
Renew
~. Not Renewing
o
Form SOG-II
Please rrake any necessary corrections to the information listed bek>w and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying for the license, this license renewal app6cation may not be used. A separate Nebraska Schedule II - County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Galling Division. Please contact the Charitable Garring Division to obtain a Form 5OG, Schedule II, or visit our Web site at ww.v.revenue.ne.gov/gaming
SSN/STATE 1.0. NAME/ADDRESS RODGERS/GUITY
3504 FAIRWAY DR PLATTSMOUTH NE 68025
RODGERS/ATA 3504 FAIRWAY DR PLATTSMOUTH NE 68048
TITLE PRESIDENT
SECITREAS
% OWN 50.00
50.00
, \
Form SOG (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE 1.0. 35-010276025
SSN/STATE 1.0. NAME/ADDRESS TITLE % OWN
ilMPORT ANT: THE FOLLOWING QUESnON MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
Since April 1. 2008, have any of the individuals listed above been convicted of, forfeited bond upon a charge of. or pled guilty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity. wiDful faillre to make requi'ed payments or reports, or fUing false reports with a governmental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
\<' ~ NO [] YES If YES, please refer to the instructions forthe information to be provided.
<
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, H is correct and comple e. I will comply wHh the provisions of the Nebraska County and CHy Lottery Act and the regulations adopted under such Act.
ert or Title Date OaYfme Ielephone NuiTber
I declare that I Rf'ie examined this application, and authorize the applicant to conduct the county/city lottery on behalf ofthe count Ic" or village named in this application.
I
V iCR CN.t;'{\'I.(LV\ 3~1 ~-IO ~D2- ~:) ~ f~ erning Official Title Date Dame lephoneNuiTber
Mail application to: NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
(Please make a copy for your records)
_/"\.----z..-Nebras~o Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS CATFISH LAKE 1006 CUNNINGHAM RD BELLEVUE NE 68005
SALES OUTLET STATE 1.0. 35-005091004
SALES OUTLET FED I.D. or SSN 470692289
LIQUOR LICENSE NUMBER 15597
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) D Keno Satellite 't7i' Keno Independent Game
Ow~s, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS CATFISH LAKE 1006 CUNNINGHAM RD BELLEVUE NE 68005
Not Renewing
D
Form SOG-II
Please rrake any necessary corrections to the information listed below and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying tor the license. this license renewal app~cation may not be used. A separate Nebraska Schedule II • County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form 5OG, Schedule II, or visit our Web site at wv.w.revenue.ne.gov/gaming
X
SSN/STATE 1.0. NAME/ADDRESS VERNON/ANTHONY W
102 E 19TH AVE BELLEVUE NE 68005
TITLE OWNER
IIMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
% OWN 100.00
Since April 1, 2008, have any of the individuals listed above been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity, wiDful faiklre to make requi"ed payments or reports, or filing false reports with a governmental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
[ ] NO [] YES If YES, please refer to the instructions forthe information to be provided.
Under nalties of law, I declare that I have examined this application, and to the best of my knowledge and belief. it is correct m lete. I will comply with the provisions of the Nebraska County and City Lottery Act and the regulations adopted under
Signature of O\M1er, Partner, Meriiler, or Title DaYtDlle leiephone Nuriiler Officer of Sales Outlet location
I declare that I have examined this application, and authorize the applicant to conduct the county/city lottery on behalf of the cou~. cit • or \,Iage named in this application.
, . Vice. C~wr'MJJY\ 3-\(0-10 4D25'134 1SS-Signat re of Gov,mlng Official Title Date DaYfme 1 eiephone Nuriiler
l) Mail application to: NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509-4855
(Please make a copy for your records)
-~ Nebrask<l Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS DEPOT INC RUM RUNNER 7007 S 181ST ST STE 106 OMAHA NE 68136
SALES OUTLET STATE 1.0_ 35-008888434
SALES OUTLET FED I.D. or SSN 470741950
LIQUOR LICENSE NUMBER 78002
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) D Keno Satellite IX!' Keno Independent Game
Ow~s, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS DEPOT INC 7007 S 181ST ST STE 106 OMAHA NE 68136
R~ Not Renewing
D
Form SOG-II
Please rrnke any necessary corrections to the information listed below and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying for the license, this license renewal appfication may not be used. A separate Nebraska Sdledule II - County/City Lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form 5OG, Schedule II, or visit: our Web site at WWN.revenue.ne.gov/gaming
SSN/STATE I.D. NAME/ADDRESS LEITNER/MARLENE L 2526 RIVER RD WATERLOO NE 68069
E-mail LEITNER/HENRY R 2526 RIVER RD PO BOX 219 WATERLOO NE 68069
TITLE SECITREAS
PRESIDENT
% OWN
100.00
Form 50G (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE 1.0. 35·008888434
SSN/STATE 1.0. NAME/ADDRESS TITLE % OWN
\IMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
Since April 1, 2006, have any ofthe individuals listed above been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity, winful faillre to make requred payments or reports, or filing false reports with a
.p\mental agency at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
~ [I YES If YES, pease refer to the instructions forthe information to be provided.
x
Under penalties of law, I d lare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I will co . h th provisions of the Nebraska County and City Lottery Act and the regulations adopted under such t.
/1) Title Oayr:ane Ielephone NuiTtler
I declal""that I~e examined this application, and authorize the applicant to conduct the county/city lottery on behalf of the countY-'1t or~age named in this application.
Vi ce (',net;' (V\(lV\ 3-[6-10 ~DZ SH 415'":;-Signature n90fficia Title DateaYtme telephone Nurmer
Mail application to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION. P.O. BOX 94855. LINCOLN. NE 68509·4855
(Please make a copy for your records)
-~ Nebraska Department of
REVENUE Nebraska Department of Revenue
County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012
COUNTY/CITY NAME COUNTY OF SARPY
COUNTY/CITY STATE 35-000806323
LOCATION NAME/ADDRESS
INTERNATIONAL HOSPITALITY INC RAMADA LIMITED 9505 S 142ND ST OMAHA NE 68138
SALES OUTLET STATE I.D_ 35-007584679
SALES OUTLET FED I.D. or SSN 470790821
LIQUOR LICENSE NUMBER 34209
Sales Outlet Location License (No license fee)
Tvpe of Location (Check one) o Keno Satellite
o Keno Independent Game Owners, Partners, Members, and Corporate Officers:
PLEASE DO NOT WRITE IN THIS SPACE
MAILING NAME/ADDRESS
INTERNATIONAL HOSPITALITY INC 9505 S 142ND ST OMAHA NE 68138
Renew
D N0t1~Wing
Form SOG-II
Please make any necessary corrections to the information listed bek:m and complete any missing information. If there has been a change of ownership in the business resulting in a different legal entity applying for the license, this license renevJal application may not be used. A separate Nebraska Sdledule II - County/City lottery Sales Outlet Application, Form 500, must be completed in its entirety and filed with the Charitable Garring Division. Please contact the Charitable Garring Division to obtain a Form SOG, Schedule II, or visit ourWeb site at WWN.revenue.ne.gov/gaming
SSN/STATE I.D. NAME/ADDRESS
GANGAHARlBHUPINDER M 17106 OAKMONT DR OMAHA NE 68136
GANGAHARISAROJ 17106 OAKMONT DR OMAHA NE 68136
GANGAHARIDEEPAK 3120 DURADO CT LINCOLN NE 68520
GANGAHARlKIRAN 3120 DURADO CT LINCOLN NE 68520
TITLE CEO/PRESIDENT
TREASURER
VICE PRESIDENT
SECRETARY
% OWN 16.50
16.50
33.50
33.50
Form SOG (Schedule II) - County/City Lottery Sales Outlet License Renewal (continuation page)
COUNTY/CITY SALES OUTLET STATE 1.0. 35-007584679
SSN/STATE 1.0. NAME/ADDRESS TITLE % OWN
jlMPORT ANT: THE FOLLOWING QUESTION MUST BE ANSWERED OR YOUR APPLICATION WILL BE RETURNED.
Since April 1, 2008, have any of the individuals listed above been convicted of, forfeited bond upon a dlarge of, or ped guitty or nolo contendere to any felony or misderreanor involving fraud, theft, any gambling activity. wiDful failire to make requred payments or reports, or filing false reports with a governmental agenCi at any level (this indudes shoplifting or issuing bad checks), OR to any other felony other than those listed above?
[ 1 NO [] YES If YES, please refer to the instructions forthe informationto be provided.
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, ~ is correct and complete. I will comply with the provisions of the Nebraska County and C~ Lottery Act and the regulations adopted under such Act.
Signature or owner, Paitner, MEmber, or Officer of Sales Outlet location
Title Date Daytone leJephone Nuri'iier
I declare that I have examined this application, and authorize the applicant to conduct the county/city lottery on behalf of the county, city, or village named in this application.
Signature of Governing Official Title Date Da)ftme I elephone Nuriiler
Mail application to: NEBRASKA DEPARTMENT OF REVENUE. CHARITABLE GAMING DIVISION, P.O. BOX 94855. LINCOLN. NE 68509-4855
(Please make a copv for vour records)
ADVANCED GAMING TECHNOLOGIES OPERATING ACCOUNT
10308 SOUTH 23RD STREET BELLEVUE, NE 68123
(402) 934-5366
~barrnk. AltofODservingyou'"
27-2-1040 3/9/2010
PAY TO THE ____ N_e_b_ra_s_k_a_D_e_p_a_rt_m_e_n_t_O_f_R_e_v_e_nu_e _____________________________________________ $ "500.00 ORDER OF:
~ 0; a
~ Five Hundred Only"*-··_··_··_·_-··············_··"······_··········********************************************************************** j ____________________________________________________________________________________________ DDL~RS I
MEMO Sarpy County
ADVANCED GAMING TECHNOLOGIES OPERATING ACCOUNT
Nebraska Department Of Revenue Licenses and Permits
DJeno Bank Acct Sarpy County
7101 3/9/2010
500.00
500.00
r -TH"'9C~C:tlsvOiDrnYHOUT ACOLOi""~D OORD~::'-ANDBAC:tGRou."l!DPluSAru;IGHTaFiro~R~iiTWATERMAA:{cmTHiBAC~ . MOLD ATA~GL[!TO \ico::ti- ~)
Sarpy County Imprest Payables Account P,nn3cieBank Vendor Number Check Date Check Number 76-1391 1:1
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Member FDIC 1049 I
SARPY COUNTY CLERK :~o~;":;~'~~"6 1548 03/09/2010 00053161 II 1210 GOLDEN GATE DRIVE, SUITE 1118:! PAPILLION, NE 68046·2895 VOID AFTER 90 DAYS FROM DATE OF ISSUE :1
Pay Exactly One Hundred Dollars and 00 cents *************
Pay To The Order Of
DEPT OF REVENUE POBOX 98923 LINCOLN, NE 68059-8923
$100.00 ,I I', Ii Ii
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_________________ ~ ____________________________ 2'~~~~~_'_"!'!:"!'~"~~'!!..,.!.""'"~~~HECK WORD,"" ___ J: ABSENCE OF PINK U.S. PATENT NUMBERS UNDER SIGNATURE INDICATES CHECK IS FRAUDULENT. PATENT NUMBERS ARE PRINTED WITH HEAT SENSITIVE INK & WILL DISAPPEAR WHEN BLOWING OR RUBBING
Sarpy County Imprest-Payatiles Account· Sarpy County CleriC Papillion. Neljrask:a 68046
Invoice Date Invoice Number Invoice Description Voucher PO No. Account Number Net Inv, Amount
03/02/2010 2010 LOTIERY LICENSE RENEWAL FEE 104509 2800352529900 100.00
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Vendor No. Vendor Name Check No. Check Date Check Amount >,
" ~EORDER )01 • u.s. tS.48:>. m8:!l; '. !>S755OG. 5&41183. 5785353. 59801;: F?cTIO OF REVEN U E 00053161 03109/2010 100.00
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Sarpy County Board of Commissioners -l'''''****
1210 GOLDEN GATE DRIVE *-l' "'i Co ** COMMISSIONERS PAPILLION, NE 68046-2895 ** ~~ @ ••••••• U+--l' Rusty Hike
593-4155 * !$¢.¢.~ 004>-$.-k District 1 www.sarpy.com *0~!l "~~1.* Joni Jones *" G; \9. * -:\0\ . .4, g ~ ,~ * District 2
ADMINISTRATOR -l'@" ~@* Tom Richards Mark Wayne -¥ . .,-' Iti .,.. * District 3
DEPUTY ADMINISTRATOR *". >j'. 1",<;, : Pat Thomas
Scott S~vick * ~"''''~ f District 4 *" ../j~IlI!;i!l~\lI~ ~ t; Rich Jansen FISCAL ADMIN.lPURCHASING AGT. **-Ie R ~ *** District 5
Brian Hanson "f-l'****
MEMO
To: Sarpy County Board of Commissioners
From: Brian E, Hanson
Re: Renewal of Keno Licenses
The Department of Revenue requires the County Board Chairman to sign Form500 to renew the keno lottery license for Sarpy County, Form 500-1 to renew Advanced Gaming Technologies lottery operator license, and Form 500-11 to renew or not to renew keno lottery licenses for all of our keno outlets, The attached Resolution and forms are on the agenda for March 16,2010,
[fyou have any questions, please call me at 593-2349.
March 12,2010
BEHIdp
cc: Mark Wayne Scott Bovick Deb Houghtaling Mike Smith
Brian E, Hanson