RES 2020-0588 - Appoint Matthew Moser manager of Butterfish ''"`LIE,,T4
4.7.• /N,... .A' " STATE OF NEBRASKA
`. •
<; ."i-, "l•; Pete Ricketts •• NEBRASKA LIQUOR CONTROL COMMISSION
`,a•\ ' ' .�Alovernor Hobert B.Rupe.
r' Executive Director
�''.,b �'—b^__=' _ 301 Centennial Mall South,5th Floor
^ Ie
" "� P.O.Box 95046
. Lincoln,Nebraska,68509-5046
_ Phone(402)471-2571 •
Fax(402)471-2814 or(402)471-2374 . •
TSR USER 800-833-7252(TTY)
.Web Address http://www.lcc.ncbraska.gov/
. June 2,2020 '
To: • CITY CLERK OF OMAHA
. Email: MMOSER@STIRNELLA.COM
Manager Name: MATTHEW MOSER • •
Licensee Name: BLACKSTONE SEAFOOD LLC
Licensee Trade Name (DBA): • BUTTERFISH
License Number: - C-122649 • ' •
Date Due: .7-17-2020
1 have attached a copy of a new corporate manager application that was submitted to the •Nebraska
• Liquor Control Commission. Please complete the following information below to indicate your
recommendation. Send back to Mary Beth Olson at mary.olsonanebraska.gov or fax to (402) 471- .
2814. If you have questions concerning this matter, please contact our office at (402)471-4893.
__ _ APPROVED
NO LOCAL RECOMMENDATION • .
• DENIED
COMMENT : (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES)
-41-Z 1 ' P14171)20— Dqtg, . -:,, Az_ 1 te I 2090 ' . .
•
Clerk Signature: ��
Date: 6.0—/-3" Zan, •
MBO
Janice M.Wiebusch Bruce Bailey Harry Hoch.
('nmmissioner • Chairman Commissioner
An Equal Opportunity Employer • .
15 100 e•..
AML Experience-Manager 05/15/2016 100 `i).`
AML Experience-Manager 04/12/2017 93 • i
•ML Experience-Manager(1.0) 06/13/2015 100
AML Experience-Manager(A) 06/13/2015 100
see
L Experience-Manager(11) 05/15/2016 100
AML Experience-Manager(1.1) 05/15/2016 100 ;,;._
AML Experience-Manager(1.1) 04/12/2017 93 .ry..
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
MANAGER APPLICATION office use
INSERT-FORM3c RE En ED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH MAY 2 6 2020
PO BOX 95046
LINCOLN,NE 68509-5046 NEBRASKA LIQUOR
PHONE:(402)471-2571 CONTROL ,-fy ; ;Q N
FAX:(402)471-2814
Website:www.lcc.nebraska.gov
MUST BE:
I Include copy of US birth certificate,naturalization paper or current US passport
i✓ Nebraska resident. Include copy of voter registration card or print out document from Secretary of
State website
,✓ Fingerprinted. See form 147 for further information,read form carefully to avoid delays in
processing,this form MUST be included with your application
,✓ 21 years of age or older
> ,..a.',-. ¢ n.t::,.. ."':` " .�'�r ._:,. � ....,ar^<-'�0�,3,''• '-"p.._.,'! Y�e...1-:' ls,. .. ....
Name of Corporation/LLC:Blackstone Seafood LLC
� b r �z � � � nd'"''4M sii•e�.��'
xe `u-i'bPf�":1' r�"s.* F.. ,4% _P..�;- '"'dW`:x..
,.
Liquor License Number: 122649 Class Type (if new application leave blank)
Premise Trade Name/DBA:Butterfish
Premise Street Address:3901 Famam Street
City: County:County:Douglas Zip Code:68131
Premise Phone Number:402-934-8979
Premise Email address:mmoser@stirnella.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. To see authorized officers or members search your license
information here.
•
SIGNATURE REQ ; t BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
Rev July 2018
Page 2 of 6
Chairman Commissioner
An Equal Opportunity Employer • .
15 100 e•..
AML Experience-Manager 05/15/2016 100 `i).`
AML Experience-Manager 04/12/2017 93 • i
•ML Experience-Manager(1.0) 06/13/2015 100
AML Experience-Manager(A) 06/13/2015 100
see
L Experience-Manager(11) 05/15/2016 100
AML Experience-Manager(1.1) 05/15/2016 100 ;,;._
AML Experience-Manager(1.1) 04/12/2017 93 .ry..
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
*del;. 7'Pl*AS:TORINTMAILLY • .; 'r •
Last Name:Moser First Name:Mattthew A
MI:
Home Address:2202 South 88th Street
Omaha Douglas
a
City: County: Zip Code:68124
Home Phone Number:402-301 -5423
Driver's License Number& State:
Social Security Number:
Date Of Birth: Place Of Birth:
Email address:mmoser@stirnella.com
EYES EIINO
Vriailith*MrifRele•Wg*-- •
A
MI:
Spouses Last Name:M oser First Name:Cathryn
Social Security Number:
Driver's License Number& State:.
Date Of Birth: Place Of Birth
?‘ 4.- •4.,' tzt:c:
- • -
YEAR 'YEAR YEAR YEAR
CITY& STATE CITY&STATE
FROM TO
FROM TO
Omaha, NE 2010 2020 Omaha,NE 2010 2020
Form 103
Rev July 2018
Page 3 of 6
`:x..
,.
Liquor License Number: 122649 Class Type (if new application leave blank)
Premise Trade Name/DBA:Butterfish
Premise Street Address:3901 Famam Street
City: County:County:Douglas Zip Code:68131
Premise Phone Number:402-934-8979
Premise Email address:mmoser@stirnella.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. To see authorized officers or members search your license
information here.
•
SIGNATURE REQ ; t BY CORPORATE OFFICER/MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
Rev July 2018
Page 2 of 6
Chairman Commissioner
An Equal Opportunity Employer • .
15 100 e•..
AML Experience-Manager 05/15/2016 100 `i).`
AML Experience-Manager 04/12/2017 93 • i
•ML Experience-Manager(1.0) 06/13/2015 100
AML Experience-Manager(A) 06/13/2015 100
see
L Experience-Manager(11) 05/15/2016 100
AML Experience-Manager(1.1) 05/15/2016 100 ;,;._
AML Experience-Manager(1.1) 04/12/2017 93 .ry..
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
F.
,74
' :ic''-y.£x '`'"' S.Y .- ,. r_.... . r `.t� ... 'waTrJr'~ 1 _ .r..a.
FROM A TO HONE
NAME OF EMPLOYER NAME OF SUPERVISOR
LNUMBER
2016 Present Meadowlark Management Matthew Moser 402-301-5423
2015 2016 The Market House Matthew Moser 402-301-5423
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 anyone who is a party to this application, or their spouse, EVER been convicted of or plead guilty to any charge.
Charge means 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 the year and month of the conviction
or plea,inclt de°traffic violation . Also list any charges pending at the time of this application. If more than one party,
please list charges by each individual's name. Commission must be notified of any arrests and/or convictions that may
occur after the date of signing this application.
ID 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
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?
DYES ONO
IF//� YES,list the name of the premise(s): f�
&4't . �.r57sist Cb r" I►4/14-Ny Li-G, B4Ckfron/E SPI-FOOD Le, Rep
Gdt,ti(1� c.cc
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?
❑Q YES ONO
Form 103
Rev July 2018
Page 4 of 6
erience-Manager(1.0) 06/13/2015 100
AML Experience-Manager(A) 06/13/2015 100
see
L Experience-Manager(11) 05/15/2016 100
AML Experience-Manager(1.1) 05/15/2016 100 ;,;._
AML Experience-Manager(1.1) 04/12/2017 93 .ry..
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
'i, _ a: -:, ;_'' ' _ `'.. - <* ti : ,r. 1 'fir' y :.}. >-_ ' 3: °F` Z r'.I
1. READ CAREFULLY. ANSWER COMPLETELY AND ACCURATELY§53-125(5)
. Has=gag who is a party to this application,or their spouse,EVE&been convicted of or plead guilty to any charge. Charge
means any 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.
Includ,.tra ..i4ela roses. Commission must be notified of any arrests and/or convictions that may occur after the date of
signing this application.
__ _YES NO
If yes,please explain below or attach a separate page
Name of Applicant Date of Where Description of Charge Disposition
Conviction Convicted
(min/'`y'") — o�n sta)
vv c -1'110W rYloser 12J2oo. nth rn IP probo.•1 rn,
I 1 2b l 1 N6 Marl uaho. . -h
at MSC S eth1h i Graf c vib1cthoicts
N ira-k 11-cm Ca ups r 'J 2.0 o"t we pers
t n)�() Dj 2 zo o� orvlrcta, NE 6 .L
2. Are you buying the business of rdarrenT l ' uo it
ro/Z a o 3 oma�ha, NE • WI r �
YES 'NO
If yea,give name of business and liquor license number
a)Submit a copy of the sales agreement
b)Include a list of alcohol being purchased,list the name brand,container size and bow many
c)Submit a list of the furniture,fixtures and equipment _
3. Was this premise licensed as liquor licensed business within the last two(2)years?
YES �NO
If yes,give name and license number
4. Are you filing a temporary ' permit(TOP)to operate during the application process?
YES 1 NO
If yes:
a) Attach temporary operating permit(TOP)(Form 125)
b) TOP will only be accepted at a location that currently holds a valid liquor license.
•
FORM 100
REV FEB 2017
PAGES
L
ager(11) 05/15/2016 100
AML Experience-Manager(1.1) 05/15/2016 100 ;,;._
AML Experience-Manager(1.1) 04/12/2017 93 .ry..
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NLCC Training Certificate Issued: Name on Certificate:
e
Applicant Name (a tyyyy) Name of program(attach copy of course completion
certificate)
*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
5. Have you enclosed form 147 regarding fingerprints?
DYES ENO
Form 103
Rev July 2018
Page 5 of 6
Form 102
REV JAN 2015
Page 5 of E
0I S
Page 5of6
Rev July 2018
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.
Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history
records of the FBI. You have the opportunity to complete or challenge the accuracy of the information
contained in FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set forth in Title 28, CFR, 16.34.
611,AlldMit
Wl
Signature o a ger Applicant Signature of Spouse
67.4,
ACKNOWLEDGEMENT
State of Nebraska
County of The foregoing instrument was acknowledged before me this
by
date NAME OF PERSON BEING ACKNOWLEDGED
Affix Seal
Notary Public signature
in other formats for persons with disabilities.
In compliance with the ADA,this application is available
A ten day advance period is required in writing to produce the alternate format.
Form 103
Rev July 2018
Page 6 of 6
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5
SPOUSAL AFFIDAVIT OF office use NON PARTICIPATION INSERT RR E„i;+'E D
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH �1 AY 2 s 2020
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 NEBRASKA LIQUOR
FAX:(402)471-2814
Website: www.lcc.nebraska.gov CONTROL COMMISSION
CM I acknowledge that I am the spouse of a liquor license holder. My signature below confirms that I will
not have any interest, directly or indirectly in the operation of the business (§53-125(13))of the Liquor Control
Act. I will not tend bar, make sales, serve patrons, stock shelves, write checks, sign invoices, represent myself
as the owner or in any way participate in the day to day operations of this business in any capacity. The
penalty guideline for violation of this affidavit is cancellation of the liquor license.
MM I acknowledge that I am the applicant of the non-participating spouse of the individual signing below. I
understand that my spouse and I are responsible for compliance with the conditions set out above. If, it is
determined that my spouse has violated(§53-125(13))the commission may cancel or revoke the liquor license.
411,
•
Signature of N N-PARTICIPATING SPOUSE Signature of APPL
Cathryn A Moser Matthew oser
Print Name Print Name
State of Nebraska,County of Douglas State of Nebraska,County of Douglas
The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged before me
this (date) this (date)
by by
Name of person acknowledged Name of person acknowledged
(Individual signing document) (Individual signing document)
Notary Public Signature Notary Public Signature
Affix Seal Affix Seal
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 116
REV NOV 2016
Page{I
nce period is required in writing to produce the alternate format.
Form 103
Rev July 2018
Page 6 of 6
4AML Intro-Manager 06/13l2015 36
AML Intro-Manager 06/1312015 36 `'*
• L lrtro-Manager(1.0) 06/1312015 36 TY-
S.i
AML Intro-Manager(LO) 06/13/2015 36
ti-Money Laundering 07/26/2010 85 .;K?
Anti-Money Laundering 07/26/2010 85 gi,:;
-s•Acknowledgement 05103/2010 100 i
AP09 Acknowledgement 05/03/2010 100
:: 1/1
requested in writing to produce the alternate format.
FORM 35-4171
Revised 1/2001
/2018 12/20/2018 12/20/2019 Attended
Course:.b'•09,Ault i r11el:s o ;es(1.4)' 12/20/201.8 12/20/2018 Days:0,Hours: Attended
Effective date far this versi n is 11/15/2017 1,Mnutes:30,
Seconds:45
versional:AcIccrTntl.fiair:r':S 7d Arrac4btt; 12/I7/2018 12/17/2018 12/17/2019 B0 Attended
,. Course:.Aecommotiato_ s and:,ccesst1:r(1.5) 12/i7/2018 .12/17/2018 80 Days:0;Hours: Attended
Effective dlte for this versbn isS/3/2618 0,minutes:25:
Seconds:27
VetsibnalEt Sanvaevinfo:mui(nseClrtySR'ecu'ds 11/26/2018 12/11/2018 Attended
Pagc 4/5