2010-074 - Sarpy County, Nebraska · 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046 Renew Not Renewing [X] D D ... (I'I\4y\ 3-1\0-10 t 5-~'5" Signature of Go (,;ing Official

$Page 1: 2010-074 - Sarpy County, Nebraska · 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046 Renew Not Renewing [X] D D ... (I'I\4y\ 3-1\0-10 ~~t 5~~-~'5" Signature of Go (,;ing Official$
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 __________________ _


E-mail

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


E-mail

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:


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

E-mail

MONASTERO/CONNIE M 709 PINE ST OMAHA NE 68108

E-mail

HASSETT/JOHN DANIEL 3211 S 57TH CIR OMAHA NE 68106

E-mail

KRUSE/RODNEY G 8129 FRANCES ST OMAHA NE 68124

E-mail

KRUSE/MARIL YN K 8129 FRANCES ST OMAHA NE 68124

E-mail

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

E-mail

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

E-mail

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

E-mail

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)



County/City Lottery Sales Outlet (Schedule II) License Renewal Application for 2010-2012


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:


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

E-mail

HOUSTON/JOHN W 5106 S 181ST PLZ OMAHA NE 68135

E-mail

LENGEMANN/JACK GERARD 10522 MONROE ST OMAHA NE 68127

E-mail

HOUSTON/SARAH VIRGINIA 5106 S 181ST PLZ OMAHA NE 68135

E-mail

HOUSTON/BRIAN MICHAEL 16428 OLIVE ST OMAHA NE 68136

E-mail

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

E-mail

TITLE SPOUSE


% 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





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



Tvpe of Location (Check onel I4J Keno Satellite !SD Keno Independent Game

Owners, Partners, Members, and Corporate Officers:


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


KRAJICEK/EDWARD L JR 2807 LAPLATTE RD OMAHA NE 68123

E-mail

STRAZDAS/CAROL A 1511 CEMETERY RD BELLEVUE NE 68123

E-mail

TITLE VICE PRES/SEC

CEO/PRESITREAS

% OWN 50.00

50.00


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





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



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

E-mail

BARGSTADT/LORI S 11078 LAKE RIDGE DR OMAHA NE 68136

E-mail

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


.,.~

Nobras~a Department of





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



S/ Keno Independent Game

Ow ers, Partners, Members, and Corporate Officers:


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

E-mail

RODGERS/ATA 3504 FAIRWAY DR PLATTSMOUTH NE 68048

E-mail

TITLE PRESIDENT

SECITREAS

% OWN 50.00

50.00

, \



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


_/"\.----z..-Nebras~o Department of





LOCATION NAME/ADDRESS CATFISH LAKE 1006 CUNNINGHAM RD BELLEVUE NE 68005

SALES OUTLET STATE 1.0. 35-005091004




Tvpe of Location (Check one) D Keno Satellite 't7i' Keno Independent Game

Ow~s, Partners, Members, and Corporate Officers:


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

E-mail

TITLE OWNER


% 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


-~ Nebrask<l Department of





LOCATION NAME/ADDRESS DEPOT INC RUM RUNNER 7007 S 181ST ST STE 106 OMAHA NE 68136

SALES OUTLET STATE 1.0_ 35-008888434




Tvpe of Location (Check one) D Keno Satellite IX!' Keno Independent Game

Ow~s, Partners, Members, and Corporate Officers:


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

E-mail

TITLE SECITREAS

PRESIDENT

% OWN

100.00


COUNTY/CITY SALES OUTLET STATE 1.0. 35·008888434


\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







LOCATION NAME/ADDRESS

INTERNATIONAL HOSPITALITY INC RAMADA LIMITED 9505 S 142ND ST OMAHA NE 68138

SALES OUTLET STATE I.D_ 35-007584679





o Keno Independent Game Owners, Partners, Members, and Corporate Officers:


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


GANGAHARlBHUPINDER M 17106 OAKMONT DR OMAHA NE 68136

E-mail

GANGAHARISAROJ 17106 OAKMONT DR OMAHA NE 68136

E-mail

GANGAHARIDEEPAK 3120 DURADO CT LINCOLN NE 68520

E-mail

GANGAHARlKIRAN 3120 DURADO CT LINCOLN NE 68520

E-mail

TITLE CEO/PRESIDENT

TREASURER

VICE PRESIDENT

SECRETARY

% OWN 16.50

16.50

33.50

33.50




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:

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~ 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

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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

Documents

2010-074 - Sarpy County, Nebraska · 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046 Renew Not Renewing [X] D D ... (I'I\4y\ 3-1\0-10 ~~t 5~~-~'5" Signature of Go (,;ing Official

2010-074 - Sarpy County, Nebraska · 1210 GOLDEN GATE DR STE 1129 PAPILLION NE 68046 Renew Not Renewing [X] D D ... (I'I\4y\ 3-1\0-10 t 5-~'5" Signature of Go (,;ing Official