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RES 2021-0930 - Appoint Sean R Blizzard manager of Dave & Buster's E-MAILED TO NLCC I.5 SS, 4 ; T 9lf.Sp STATE OF NEBRASKA 1 Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION Hobert B.Rupe 4 ��j.� Governor p Executive Director 4''N gacn t_,;e 301 Centennial Mall South P.O.Box 95046 Lincoln,Nebraska,68509-5046 Phone(402)471-2571 Fax(402)471-2814 or(402)471-2374 TRS USER 800-833-7352(TTY) Web Address https://www.lcc.nebraska.gov Today's Date: August 03, 2021 From: Lisa Steward To: City Clerk of Omaha I have attached a copy of a new corporate manager application submitted to the Nebraska Liquor Control Commission. Please complete the following information below to indicate your recommendation. Licensee Name: Dave & Buster's of Nebraska Inc Trade Name (DBA): Dave & Buster's License Number: 1-068065 Manager Name: Blizzard, Sean R Due Date: September 17, 2021 rat APPROVED n NO LOCAL RECOMMENDATION n DENIED COMMENTS: (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES) 4- 35" A . 3 Qj Clerk's Name: Date: 3 2-?CZ Kim Lowe Bruce Bailey Harry Hoch Commissioner Chairman Commissioner .17 Equal Opportunity Employer ail.google.com/mai I/u/0?ik=cd387c45eb&view=pt&search=all&permthid=th read-a%3Ar-1944631688636560899%7Cmsg-a%3Ar23596233231... 1/2 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 28, CFR, 16.34. ****Please Submit this form with our completed ap lication to the Liquor Control Commission**** Trade Name 11/ 1/111(, a ire ` d Name of Person Bein Fine rinted:Inc•�_ ,•. Date of Birth: Last 4 SSN: Date fingerprints were t en: /1`1/..1 Location where fingerprints were taken: L L.t\1 S 1o`b 5\- Ul�,1u ri c,`031 Ho, was payment made to NSP? NSP PAYPORT OCASH OCHECK SENT TO P CK# My fingerprints are already on file with the commi ton—fingerprints completed for a previous application less than 2 years ago? YES O A.)() SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FnRM 1117 103 Rev July 2018 Page 6 of 6 MANAGER APPLICATION Office Use INSERT-FORM 3c RECEIVED NEBRASKA LIQUOR CONTROL COMMISSION 301 CENTENNIAL MALL SOUTH AUG 03 2021 PO BOX 95046 LINCOLN,NE 68509-5046 NEBRASKA LIQUOR PHFAX: (442)7 4-2814 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 officers t/ corporate officer or member must be an individual on file with the Liquor Control Commission • fingerprints are required. See form 147 for further information,read form carefully to avoid delays 4./ in processing,this form MUST be included with your application. V Provide a copy of one of the following:US 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 or print document from Secretary of State website with application ✓'4f't A;("' xP /Lf/2oz.`4 Spouse who will not participate in the business, spouse must: • complete the Spousal Affidavit of Non Participation Insert(must be notarized). The non- participating spouse completes the top half;the manager completes the bottom half. Be sure to 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 rx • Fingerprints are required. See form 147 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: 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 2100008092 Form 103 Rev July 2018 Page 1 of 6 NSP PAYPORT OCASH OCHECK SENT TO P CK# My fingerprints are already on file with the commi ton—fingerprints completed for a previous application less than 2 years ago? YES O A.)() SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FnRM 1117 103 Rev July 2018 Page 6 of 6 MANAGER APPLICATION woe Uso HECLIVED INSERT-FORM 3c NEBRASKA LIQUOR CONTROL COMMISSION AUG 0 3 2021 301 CENTENNIAL MALL SOUTH PO BOX 95046 NEBRASKA LIQUOR LINCOLN,NE 68509-5046 CONTROL COMMISSION PHONE:(402)471-2571 TAX:(402)471-2814 • Website:www.icc,nebraska.gov MUST BE: ✓ Include copy of US birth certificate.naturalization paper or current US passport ✓ 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 ...:-!0.i arc., !-;... :_.7e,f.�.� yy .))..++..,,v.� '!)•;3';if C' a �...- �,It� �.. TS�t i �r.k�# .$ .,..rvY v! _tte`-J? {sa •q r irr !2{ itt:�.a.,_'+ 99...� ' 1 , t r�••.`•.•'•'-!1 l,ll�1.VV aJ..3,';ri f: .. .x-....:Cy, t.ye., ;.-,,y�F 1'\..5.., -S :` Yin.•,' N r: �•_P{>.t¢S r:..F•„+ti dh.}�'..� .r..:CSrJ• Name of Carporation/LLC: DAVE & BUSTER'S OF NEBRASKA, INC. `SPic 'e' ,j: - F'..rp„3F"N ,: t \ Y ty k !.;''+f«�'H r f. 1'SK . . �l�e�� Cy7'�� p�r.�- �.:a� 4� ( Y{Y; }'�,�"�Ft"� �-'��f`�-��•`�J..1 ^JfL M� 1T' 4 . J L 'IC h+�. J LEYC. Liquor License Number: Q68065 Class Type I (if new application leave blank) Premise Trade Natne/DBA: DAVE & BUSTER'S Premise Street Address: 2502 S. 133 PLAZA, SUITE-'1--1 5C City: OMAHA County: DOUGLAS Zip Code: 68144 Premise Phone Number:(402) 778-3915 Premise Email address:LICENSING@DAVEANDBUSTERS.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 REQUIRED BY CORPORATE OFFICER I MANAGING MEMBER (Faxed signatures are acceptable) Poem 103 Rev July 2016 Page 2 of 6 Page 1 of 6 NSP PAYPORT OCASH OCHECK SENT TO P CK# My fingerprints are already on file with the commi ton—fingerprints completed for a previous application less than 2 years ago? YES O A.)() SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FnRM 1117 103 Rev July 2018 Page 6 of 6 Mitigatitaitraiirafinlanentar * 1,71Wie. ra,". ,T21 Last Name: First Name: S MI: Home Address: 54-A i•-)41,1 1 c) c),(\ City: G•e_V\v‘tht\-ON‘ County: D04,5,...s Zip Code: (0 8001 Home Phone Number: 1-10a-alLt 91 3 5 Driver's License Number&State: Social Security Number:_11.11111111111111111 Date Of Birth MI= Place Of Birth: e cktr4"1 es 11-e. 0 k Email address: S.fo a fea cvst...) 7.0"Aft6.4.'"'t itle10.41.1.3liti4011t*rti;;IVI&AV41.2 .1 t YES ONO k; Spouses Last Name: IS\cliSkrd . First Name: J MI: Social Security Number: Driver's License Number&State: Date Of Birth: Place Of Birth: 14.) t i7:1:w71,r-,:srm:44.vorkfreiihT,,rofi, • 444, rt.r, YEAR YEAR YEAR YEAR CITY&STATE CITY&STATE FROM TO FROM TO etrr,xy\}) k5\a,A3 NIC 201S Om 0\N-0. t`-) le\A 1,b\1 S 1 6Aies‘t tr,,,;N\ sm_ c•-•••• .o\-1 n\mot,46,,`) PO AS\ • Form 103 s Rev Juty 2018 FargO3of6 Cy7'�� p�r.�- �.:a� 4� ( Y{Y; }'�,�"�Ft"� �-'��f`�-��•`�J..1 ^JfL M� 1T' 4 . J L 'IC h+�. J LEYC. Liquor License Number: Q68065 Class Type I (if new application leave blank) Premise Trade Natne/DBA: DAVE & BUSTER'S Premise Street Address: 2502 S. 133 PLAZA, SUITE-'1--1 5C City: OMAHA County: DOUGLAS Zip Code: 68144 Premise Phone Number:(402) 778-3915 Premise Email address:LICENSING@DAVEANDBUSTERS.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 REQUIRED BY CORPORATE OFFICER I MANAGING MEMBER (Faxed signatures are acceptable) Poem 103 Rev July 2016 Page 2 of 6 Page 1 of 6 NSP PAYPORT OCASH OCHECK SENT TO P CK# My fingerprints are already on file with the commi ton—fingerprints completed for a previous application less than 2 years ago? YES O A.)() SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FnRM 1117 103 Rev July 2018 Page 6 of 6 ��-�" «'1 ��':�-tt" i� ��v�-` Wry t,7 44 t cr: CAI fi }f! i, F E i�:. e I ,(- ri 7 t! i ti. s..+ y •:N.s�a�.=; �F;i„ _;'hh: a�.`s'4s' w.43_. r t.�z 'a� , . . I,a6,v .F i FROMYE AR TO NAME OF EMPLOYER NAME OF SUPERVISORNUMBER TELEPHONE auto a.0a‘, Lo.tmc4r 5 1 311. 351 424S 1d411 201.o (.pc0.1 ,( Rio k:44 ,.4. E �t'J) i5^.50/439Z 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. Cliarge 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 n ame. Commission must be notified of any arrests and/or convictions that may occur after the date of signing this application. RI YES ❑ NO If yes, please explain below or attach a separate page. Date of Where Description Name of Applicant Cor Action Convicted of Disposition (mm/yyyy) (City&State) Charge See-mg-aches( 2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or any other state? YES ENO IF YES,list the name of the tem e(s): ONO 64.e.e-so (440 L.16.0p 3. Do you, as a manager, qualify under Nebraska Liquor Control Act J§53-131.01)and do you intend to supervise, in person,the management of the business? 11YES ONO Form 103 Rev July 2018 Page 4of6 le) Poem 103 Rev July 2016 Page 2 of 6 Page 1 of 6 NSP PAYPORT OCASH OCHECK SENT TO P CK# My fingerprints are already on file with the commi ton—fingerprints completed for a previous application less than 2 years ago? YES O A.)() SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED FnRM 1117 103 Rev July 2018 Page 6 of 6 4 List the alcohol related training and/or experience(when and where)of the person making application. * LCC Training Certificate Issued:— Name on Certificate: _ Applicant Name Date Name of program(attach copy of course completion (mm/YYYY) certificate) (Al e•9 Q zt a Via c4 441 +j wk r For ivuk, ,i c v s k `E'-t614-s Got 4-b (-AO ..v• W )% av►e) dal el:,e • Qk.-4 ;el tJ Sa 0 e}cc.W1 Prot pr_OLYZ0.4_3 '�c•� -'r to W45rQ► 61, ec,ed SSA *For list of NLCC Certified Training Programs see training E perience: Applicant.Name/Job Title Date of Name&Location of Business: Employment: 5. 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CI I (I) x tgig cze Lu 13 i..1 art of "-" x if Kp� V-4,if.'4- rs-s� raj . ,-y,,gv!?sff'.4'Fa"3.a`-a §y tp e ':.t' ki,i 11VO` 9 . �E!if 0J.'-!_:R ,K;e', Q ti) C.-•t(e i F' ,, -''^N.�:i.. i 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 653-131.01)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 m e attached. The undersigned understand and acknowledge that any limns 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. C 1'jAize ,t natur f Spouse Signature of onager Applicant p ACKNOWLEDGEMENT State of Nebraska County of Li I1A The foregoing instrument was acknowledged before me this �� P-b „‘ by 4cpo'klc �t2?C,i'ot oC-S NAME OF PERSON BEING AC KNOW Pakk GED _./... _____, Affix Scat Notary Public signature BE is i.110TARY4tats of'Nieresiu DA*4i01 ALEXANDE} . losies *Gomm Of..JarWry®,2023 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 Pop 6of6 SPOUSAL AFFIDAVIT OF orn,use RECEIVED NON PARTICIPATION INSERT NEBRASKA LIQUOR CONTROL COMMISSION t",t 301 CENTENNIAL MALL SOUTH PO BOX 95046 LINCOLN,NE 68509.5046 NEBRASKA I i i J C3 R PHONE:(402)471-2571 FAX.(402)471.2814 CONTRO COMMISSION website: vnvw.lccarcbmska.gov X 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 ahcivcs, write chocks,sign invoioos, 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. [X • 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. J II qlar 1,0 Jake)/ eb (1244 S gnature of N e • • •T ATIN OUSE Signature of APPLIC \e)(\b e l 7.7—Cj' (11 Print Name Print Name State of Nebraska,County of P/oK 5' State of Nebraska,County of DO u U la_S v ed before me The foregoing instrument was acknowledged before me The foregoing instrument was acknowledged this '"ukY ff 264.k aaa% (date) this c�%y 3041% aoa (date) if� r �/'� ( l,1 Z'1r.�t`p� by :�?e�lti 9ph OX'� l 22) by 1 �N' Name of arson acknowledged Name ofperson acknowledged (Individual signing document) (Individual signing document) o Ty Public Signature Public Signature GUIERAI WARM*of Meltluka WIERAL NOTARY-State of Nebraska LVABOMIEXANDER AMar AWALotANaan rbComm Exp.JaveY 3.2023 Ocao.Esp.stivrty S.2023 In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities. A ten day advents period is requested in writing to produce the aitemate format. FORM 116 REV NOV 2016 Fugal le 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 Pop 6of6 PR VACY ACT STATEMENT/ oftweb SU MISSION OF FINGERPRINTS/ .. .,, ,:... R. . , PA MENT OF FEES TO NSP-CID NE • SKA LIQUOR CONTROL COMMISSION 301 ENTENNIAL MALL SOUTH PO :OX 95046 .: :' Iiii F ..''.. LINE OLN,NE 68509-5046 � '• p�:1 lj�'j� '101\i. . :. PH�i E:(402)471-2571 .'0, o"t4sij':antotAbefol.0 rig-pages... PA I,(402)471-2814 Web.ite:www.lcc.nebraska.gov T. S FORM IS REOUIRED TO BE SIGNED BY EACH PERSON]BEING FINGERPRINTED: DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS: • FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REOUIRED FEE TO THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIOUOR LICENSE • Fee payment of S45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol; It is recommended to make pay:r,ent through the NSP PayPort online system at www.ne.gov/go/nsp Or a check made payable to 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 12a'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 sub►Witted with the application. • App;lcant 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 cont tned in the FBI identfcation recor 1 The procedures for obtaining a change, correction,or updating a F I identification record are set forth In Title 28, CFR, id,34. *** Please Submit this form with your completed application to the Liquor Control Commissions*** Tradj Name ')s...k. (-..t) 93,,s-s.i Name of Person Being Finge rinted: Sctri1/4 t3Y" .. cod Date of Birth: Last 4 SSN: Date fingerpri I Z,ei i Z t Loca ion when fingerprints were to en: MSp-omdli ....- How was payment made to NSP? kIlN P PAYPORT ❑CASH ❑CHECK SENT TO NSP CK# My ngerprints are already on file with the commission—fingerprints completed for a previous. appli ation less than 2 years ago?YES 0 G PE TIRED OF ERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 day advance period is required in writing to produce the alternate format. Form 103 Rev July 2018 Pop 6of6 8/5/2021 Enterprise Mail-MANAGERSAPPLICATION FOR OMAHA CITY COUNCIL HEARING Gmail Johnson (CCIk) <carman. ohnson cit ofomaha.or > J @ Y 9 MANAGERS APPLICATION FOR OMAHA CITY COUNCIL HEARING 1 message Carman Johnson (CCIk) Thu, Aug 5, 2021 at 5:43 <Carman.Johnson@cityofomaha.org> PM To: SEAN.BLIZZARD@daveandbuster.com, JILL_VALACHOVIC@daveandbusters.com Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing (CCIk)" <kmberly.pulliam@cityofomaha.org>, "Autumn Drickey (CCIk)" <autumn.drickey@cityofomaha.org> Good late day RE: DAVE & BUSTER'S OF NEBRASKA, INC 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, AUGUST 31, 2021. 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. I ALSO NEED THE DATE OF BIRTH FOR SEAN R. BLIZZARD, PLEASE SEND ME 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 https://mail.google.com/mai I/u/0"ih=cd387c45eb&view=pt&search=all&permthid=thread-a%;F,r-3148036324725928849%7Cmsg-a%3Ar10291479203... 1/2 cation 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 cont tned in the FBI identfcation recor 1 The procedures for obtaining a change, correction,or updating a F I identification record are set forth In Title 28, CFR, id,34. *** Please Submit this form with your completed application to the Liquor Control Commissions*** Tradj Name ')s...k. (-..t) 93,,s-s.i Name of Person Being Finge rinted: Sctri1/4 t3Y" .. cod Date of Birth: Last 4 SSN: Date fingerpri I Z,ei i Z t Loca ion when fingerprints were to en: MSp-omdli ....- How was payment made to NSP? kIlN P PAYPORT ❑CASH ❑CHECK SENT TO NSP CK# My ngerprints are already on file with the commission—fingerprints completed for a previous. appli ation less than 2 years ago?YES 0 G PE TIRED OF ERSON BEING FINGERPRINTED FORM 147 REV AUG 2020 day advance period is required in writing to produce the alternate format. Form 103 Rev July 2018 Pop 6of6