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RES 2020-1074 - Appoint Elizabeth M Wallace manager of 801 Grill iis-s,rq,,1 E-MAILED TO NLCC �)- 9 2c oF, cam, rF oly+ — STATE OF NEBRASKA t�`: . 't�:` 4;y Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION � *4`�! 4'4.27 Hobert B.Rupe l :�_; �a Governor +h�l • '� ! Executive Director hu eqR ash° 301 Centennial Mall South,5`h Floor 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.nebraska.gov/ October 28, 2020 To: CITY CLERK OF Omaha Email: carman.johnson@cityofomaha.org elizabeth.butler@cityofomaha.org kimberly.pulliam@cityofomaha.org Manager Name: Wallace, Elizabeth M Licensee Name: Pig & Finch Oma LLC Licensee Trade Name (DBA): 801 Grill License Number: 11 06334 Date Due: December 11, 2020 • • I 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 Lisa Steward at Icc.frontdesk(a�nebraska.gov or fax to (402) 471- 2814. If you have questions concerning this matter, please contact our office at (402) 471-2572. APPROVED NO LOCAL RECOMMENDATION DENIED COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) g 21)2D )- • r • Clerk Signature: Date: 12./6//767.r) LS • Janice M.Wiebusch Bruce Bailey Harry Hoch Commissioner Chairman Commissioner • An Equal Opportunity Employer 1U� 3`' MANAGER APPLICATION Office Use r 1SERT-FORM3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSI.OTT OCT 2 7 2OZ0 301 CENTENNIAL MALL SOUI'I I PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHONE:(402)471-2571 CONTROL COMMISSION FAX:(402)471 2814 • Website:www.lcc.nebraska.gov FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE PROCESSED MANAGER MUST: • Complete all sections of the application. Be sure it is signed by a member or corporate officer. V corporate officer or member must be au individual on file with the Liquor Control Commission • Fingerprints are required. See form 1.47 for further information,read form carefully to avoid delays in processing, this form MUST be included with your application. • Provide a copy of one of the following.: US birth certificate,naturalization papers or current US passport(even if you have provided this before) NZ* Be a registered voter in the State of Nebraska,include a copy of voter card or print document from Secretary of State website with application Spouse who will not participate in.the business, spouse must: • Complete the Spousal Affidavit of Non Participation Insert(must be notarized). The non- K participating spouse completes the top half; the manager completes the bottom half. Be sure to 1v complete both halves of this form. • Need not answer question#1 of the application Spouse who will participate in the business,the spouse must: • Sign the application • Fingerprints arc required. See form 147 for further information,read form carefully to avoid delays \Q< in processing,this form MUST be included with your application. • Provide a copy of one of the following:birth certificate,naturalization papers or current US passport (even if you have provided this before) • Be a registered voter in the state of Nebraska,include a copy of voter card with application • Spousal Affidavit of Non Participation Insert not required 2000010986 row I03 Rev July 2013 Page 1 of 6 MANAGER APPLICATION Office 13se • INSERT-FORM 3c NEBRASKA.LIQUOR CONTROL COMMISSION li C T 2 i 2020 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRA SKA LIQUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE:(402)4712571 FAX:(402)471.2814 Website:www lccsebraska.gov MUST BE: ✓ Include copy of US birth certificate.naturalization paper or current US passport ✓ Nebraska resident Include copy of voter registration card orprint 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 - is:.-�,X•.�c --••r::a '- �•-.�{ YSa•r-..:. ;�V:r,y=,•.Z�::.�.�• 4i ••v�. _ctia��"-�'. �t.iy.: �Dk'{3;(-I,�L��;�3' f, s4'�Cry...,,:��r r.• � .� .+ �,� =�••' "� Name of Corporation/MC: Vi \fin I)3$ SSi7iersikr6Vt.UVIA rk d70U e ��`;>t%�c'rkV�^•r.p .�.�• « ..-,;<:> .::�F;:i •�.rc��.:�r: r.,.-� �.n'o.`S G:�. `•w/•°i 'fie `3.�T.�. �•ltilXi��'•�otfTld�IL -5u,r-ti��'�r,%• ,,;Y�.f :��yr.• _. °>'-t..a�?�,�=a��. '`t0� �t'�`?-^�.;�-�">,�r si%:F;•'�3t7,'-.>.�..,�"._..•,. � x�:.. .r>':. -:i•L`>`:Fic;-:•f- •.:d':�2'Wit ti ..-.:a;i .-.Y...r..�.'.�'!:: ':.. ..- ^1�1a. . t'L `•- .-��s Liquor License Number: 1 CAA k Class Type - (if newappbaatio.UzaveBlank) Premise Trade Name/DBA: $O\ Cry2..i I Premise Street Address: 10��-1 WL(A AG Si-- City: ( r(Tt,h Ck County: P ffjl6t j Zip Code: (AZ Premise Phone Number: 402- S42 S SAP Premise Email address: SO\ &1\ O 'I1Qi e .0 ' The individual whose name is listed as a corporate officer or managing member as reported.on insert for n3a or 3b or listed with the Commission. To see authorized officers or members search your license information here. p- isiGioftw nvuTRED BY'CO O 2ATE of 1CM, IVAINAGANTO.MVO. (Faxed signatures arc acceptable) Form 103 Rev laly2018• Page 2 of 6 0986 row I03 Rev July 2013 Page 1 of 6 !Mii4geei nuit.be.etiiii:Pleted.belOw.- Last Name: Vi \V&I.e., First Name: tlinetVak MI: OA Home Address: iEV N . City: Oni\AV:A County: Do-vd \C(..S Zip Code: Home Phone Number: k° Driver's License Number& State: Social Security Number: Date Of Birth: Place Of Birth: tin e, Wyln 515\1/1.11/1 Email address: ekillik Vetkin .krnarS p wyr Ai-iyc:603:a#ie-ciyxy:e6th-oktefii6-ws-;wdaAfl-r—:6iavEfost-*':ifJ..orfsiTfwdwioagweriTabi-iyi-R&-cir:Ao []YES 124 NO Spouses Last Name: First Name: MI: Social Security Number: Driver's License Number&State: Date Of Birth: Place Of Birth: FT:01002MX710-0;07- Mqt0513;W:§W*73,7(§71TOIT::XffggikFE41-7-qi€137.775)-31TFAC-44;71 CITY& STATE YEAR YEAR 'YEAR YEAR CITY& STATE FROM TO FROM TO OlYWNOt) \VP-) fiA) 0 ViserVell- Form 103 Rev July 2018 Page 3 of 6 G:�. `•w/•°i 'fie `3.�T.�. �•ltilXi��'•�otfTld�IL -5u,r-ti��'�r,%• ,,;Y�.f :��yr.• _. °>'-t..a�?�,�=a��. '`t0� �t'�`?-^�.;�-�">,�r si%:F;•'�3t7,'-.>.�..,�"._..•,. � x�:.. .r>':. -:i•L`>`:Fic;-:•f- •.:d':�2'Wit ti ..-.:a;i .-.Y...r..�.'.�'!:: ':.. ..- ^1�1a. . t'L `•- .-��s Liquor License Number: 1 CAA k Class Type - (if newappbaatio.UzaveBlank) Premise Trade Name/DBA: $O\ Cry2..i I Premise Street Address: 10��-1 WL(A AG Si-- City: ( r(Tt,h Ck County: P ffjl6t j Zip Code: (AZ Premise Phone Number: 402- S42 S SAP Premise Email address: SO\ &1\ O 'I1Qi e .0 ' The individual whose name is listed as a corporate officer or managing member as reported.on insert for n3a or 3b or listed with the Commission. To see authorized officers or members search your license information here. p- isiGioftw nvuTRED BY'CO O 2ATE of 1CM, IVAINAGANTO.MVO. (Faxed signatures arc acceptable) Form 103 Rev laly2018• Page 2 of 6 0986 row I03 Rev July 2013 Page 1 of 6 YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE FROM TO NUMBER t-}�t'1 the 4' liltWLUlt~Ll1'Yt ChwiS Mid S f�tacit L i' °t►�-�i�£�-tt 31 OW O 4\ri eNvAs_ its`(\ ^) - 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 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,include traffic violations. 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. Ea YES. ❑ NO If yes,please explain below or attach a separate page. Date of Where Description Name of Applicant Conviction Convicted of Disposition mm/AAA Cit &State Charge 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? IYES ONO IF YES,list the name of the premise(s): rsDk C`ki\AN \ - tiiU3 rni .rr S� 3_ Do you, as a manager, qualify under Nebraska Liquor Control Act(4$53-131.011 and do you intend to supervise, in person,the management of the business? AYES ❑No Form 103 Rev July 2013 Page 4 of 6 • horized officers or members search your license information here. p- isiGioftw nvuTRED BY'CO O 2ATE of 1CM, IVAINAGANTO.MVO. (Faxed signatures arc acceptable) Form 103 Rev laly2018• Page 2 of 6 0986 row I03 Rev July 2013 Page 1 of 6 4. List the alcohol related training and/or experience(when and where)of the person making application. *NLCC Training Certificate Issued:'(-b 51 inl 1 tw Name on Certificate: @ jl2A X.A►' Man Q. Wall,4 te Date Name of program(attach copyof course completion Applicant Name (��) P gT � certificate) c 1 -1/4G\ WitVatt ts1 tS021r '=ST oniin-. - C.P13 & k1 Y- ct -ct *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? YES f1NO ' Form 103 Rev July 2018 Page 5 of 6 AP s7,3 ca . . ,,, , . co 0 , ---<.-.<.c..0-_cff.,.O.cg..O.,rff...,r--a_r_j.,-)\ rff.d.N r-.-.,..2.,67.-",'N...2_,,,r-ba,r5s,.„,cg...,6-.9',,,rg..0_,a,g..."----.L.,••.,_ . . .),-•w,-,-{,T.in,r!itz-,.4,,,v-a ..L'Ailtgateing..3.1sa...5-..-11-7-zaro.zitz,14.3:,:-.FrK:m:e-iEv;:i--7.t.z c..,-,), ..-. ..,,,,,_ ..........,4 .-_.k..f.-_t-a_,--------_d-.11N-_ -------—---.4.• IA.- _l. 1. i,l.L__";;;S:, , 11) (i) CIS :•.,...,. it";t 1.3) i .41.1.e i . :.c.',.., ,s....1 f t .);-:'! 2 0. :".i? ID CI ,.:7:•;;-,t473 ......, 73 13 m 0 CD -- ,:....i- EL::.,:n,s,-, .. , i..._ 5 eist, -.,.,,,::1,...3 1,41 5:j: cr 51 0 i.k. ,.:.. i ....,,, i •41‘* ' ::::::'; '1/4.3, CC 3- Q fi! g 0 Potio-ii ti ‘,. . ez,f;f.,7,. oi 0 0 Irsa. -ic.i ••,i r:41.: - F ki.:-.t,. ,.••'r ° : o c CO 5. z esa. X Ai EI: (...> ::::!.:,. • 0 M , I 1 —• ;:r'•;:l 1--....z L, ..,, i L., .iT.F: .,0•V ,,,,,,,i,tr..) ittu . . .. ,-. . ---,..... m,..-..-3. . - in person,the management of the business? AYES ❑No Form 103 Rev July 2013 Page 4 of 6 • horized officers or members search your license information here. p- isiGioftw nvuTRED BY'CO O 2ATE of 1CM, IVAINAGANTO.MVO. (Faxed signatures arc acceptable) Form 103 Rev laly2018• Page 2 of 6 0986 row I03 Rev July 2013 Page 1 of 6 — - _ _ • ; .PERS.Oat2 711.:4 AND UNSESTT Off`f1 ffg-RU l r R {ii 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)shaII be deemed guilty of perjury and subject to penalties provided by law. (Sec 453-131.01)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. kG� lgnature of Manager Applicant Signature of Spouse 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 compliance with the ADA, this application is available in other formats for persons with disabilities. A ten day advance period is required in writing to produce the alternate format. Form 103 • Rev July 2018 Page 6 of b PRIVACY ACT STATEMENT/ affjce, lse_o;�!y SUBMISSION OF FINGERPRINTS / Tit...,•r.i �+ ,.., . 11111 PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION ( 11 '��'�' 301 CENTENNIAL MALL SOUTH t.��r.,, PO BOX 95046 rsate stamp HERE ONLY LINCOLN,NE 68509-5046 -`-' PHONE: (402)471-2571 FAX: (402)471-2814 Website:www.tcc.nebraska.gov THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERPRINTED: DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make payment through the NSP PayPort online system at www.ne.gov/go/nsp Or a check made payable to NSP can be mailed directly to the following address: ***Please indicate on your payment who the payment is for(the name of the person being fingerprinted) and the payment is for a Liquor License*** The Nebraska State Patrol—CID Division 3800 NW 12'h Street Lincoln,NE 68521 • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID Applicant(s)will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application. 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 a FBI identification record are set forth in Title 28, CFR, 16.34. Trade Name: O\ Gr-A\ Name of Person Bring Fingerprinted: €i.Z.G1 19L INC MAC e Date of Birth111111._ Last 4 SSN: Date fingerprints were taken: 4', 1 1 7,6?-0 Location where fingerprints were taken: I 'AVSk(,t Q c 1r_�Pr 4I 1 G.{00''Si- How was payment made to NSP? Oorhcf'` r 31 NSP PAYPORT OCASH OZCHECK SENT TO NSP CK# -UCH d c recCor�deipsf y fingerprints are already on file with the commission—fingerprints completed for a previous application less than 2 years ago? YES E 1) Q (i6etttace— SIGN T E REQUIRED OF PERSON BEING FINGI RPRINTED FORM 147 REV MAY 2018 PRIVACY ACT STATEMENT/ Office Use.cnly SUBMISSION OF FINGERPRINTS / RECEIVED PAYMENT OF FEES TO NSP-CID NEBRASKA LIQUOR CONTROL COMMISSION I CT 2 7 2020 301 CENTENNIAL MALL SOUTH kn Sarno FERE ONLY PO BOX 95046 1'etHASKA LIOOLJOI3 LINCOLN,NE 68509-5046 C,c; UT & rylcaJlSKilltes PHONE: (402)471-2571 FAX: (402)471-2814 Website: www.lcc.nebraska.gov THIS FORM IS REQUIRED TO BE SIGNED BY EACH PERSON BEING FINGERP.RE TED: • DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR LICENSE • Fee payment of$45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make payment through the NSP PayPort online system at tvww.ne.env/go/nsp Or a check made payable to NSP can be mailed directly to the following address: ***Please indicate on your payment who the payment is for(the name of the person being fingerprinted) and the payment is for a Liquor License*** The Nebraska State Patrol—CID Division 3800 NW 12`h Street Lincoln,NE 68521 • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID Applicant(s) will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application. Applicant Notification and Record Challenge: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedures for obtaining a change, correction, or updating a FBI identification record are set forth.in Title 2$, CFR, 16.34. ****Please Submit this form with your completed application to the Liquor Control.Commission**** Trade Name Name of Person Being Fingerprinted: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous application less than 2 years ago? YES, 6244A U'aa/ .` SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 SON BEING FINGI RPRINTED FORM 147 REV MAY 2018 11/3/2020 Enterprise Mail-Re:MANAGERS APPLICATION FOR OMAHA CITY COUNCIL HEARING Gmail Carman Johnson (CCIk) <carman.johnson@cityofomaha.org> Re: MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING 1 message Carman Johnson (CCIk) • Tue, Nov 3, 2020 at 12:50 <Carman.Johnson@cityofomaha.org> PM To: 801 GRILLOMA@801 restaurants.com, elizabeth.marie@outlook.com Cc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <Kimberly.Hoesing@cityofomaha.org> SORRY I ALSO NEED THE DATE OF BIRTH FOR ELIZABETH WALLACE, PLEASE SEND THIS INFORMATION AS SOON AS POSSIBLE. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax Carman.johnson@cityofomaha.org On Tue, Nov 3, 2020 at 12:42 PM Carman Johnson (CCIk) <Carman.Johnson@cityofomaha.org> wrote: Good afternoon https://mail.google.com/mail/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-2292692748577905015%7Cmsg-a%3Ar-6511966816... 1/2 ion 3800 NW 12`h Street Lincoln,NE 68521 • Fingerprints taken at NSP LIVESCAN locations will be forwarded to NSP—CID Applicant(s) will not have cards to include with license application. • Fingerprints taken at local law enforcement offices may be released to the applicants; Fingerprint cards should be submitted with the application. 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 the FBI identification record. The procedures for obtaining a change, correction, or updating a FBI identification record are set forth.in Title 2$, CFR, 16.34. ****Please Submit this form with your completed application to the Liquor Control.Commission**** Trade Name Name of Person Being Fingerprinted: Date of Birth: Last 4 SSN: Date fingerprints were taken: Location where fingerprints were taken: How was payment made to NSP? ❑NSP PAYPORT ❑CASH ❑CHECK SENT TO NSP CK# My fingerprints are already on file with the commission—fingerprints completed for a previous application less than 2 years ago? YES, 6244A U'aa/ .` SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 SON BEING FINGI RPRINTED FORM 147 REV MAY 2018 11/3/2020 Enterprise Mail-Re:MANAGERS APPLICATION FOR OMAHA CITY COUNCIL HEARING RE: PIG & FINCH OMA, LLC The Omaha City Clerk's Office has received your application from the Nebraska Liquor Control Commission. The Omaha City Council will hold a public hearing on this request on Tuesday, November 24, 2020. City Council meetings start at 2:00 PM and are located in the Legislative Chambers in the Omaha/Douglas County Building located at 1819 Farnam Street, Omaha, NE 68183. You or a representative is required to attend the meeting. Please notify me if you have any questions. Thanks Carman Johnson Liquor Clerk • City of Omaha/City Clerk 1819 Farnam Street Suite LC-1 Omaha, NE 68183 402-444-5324 402-444-5263 fax • Carman.johnson@cityofomaha.org https://mail.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=thread-a%3Ar-2292692748577905015%7Cmsg-a%3Ar-6511966816... 2/2