RES 2022-0487 - Appoint Michael J Church manager of Godfather's Pizza 28033 li
E-MAILED TO NLCC —
•
—:p�,'_� ,r- STATE OF NEBRASKA
1. : .,e;,I Pete Ricketts NEBRASKA LIQUOR CONTROL COMMISSION
d '7 d a2' Governor Hobert B.Rupe
$iti: J
1 °,. ({ „-;' J Executive Director
�k`;1kc:rr yrt -'' 301 Centennial Mall South
P.O.Box 95046
Lincoln,Nebraska,68509-5046
Phone(402)471-2571 I
Fax(402)471-2814 or(402)471-2374
TRS USER 800-833-7352(TTY)
Web Address https://www.lcc.nebraska.gov
Today's Date: April 15, 2022
From: Rebecca Roberts (rebecca.roberts@nebraska.gov)
To: Omaha City Clerk
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: Godfather's Pizza Inc
Trade Name (DBA): Godfather's Pizza 28033
License Number: A-083679
Manager Name: Church, Michael J
Due Date: May 31, 2022 •
APPROVED •
NO LOCAL RECOMMENDATION
DENIED •
COMMENTS: (YOU MAY ATTAC H MINUTES AND/OR ADDITIONAL NOTES)
I ) 6- ij2-022— Oirl 041 1 7, gOaa
•
Clerk's Name: Date: `T 19- 70%1
Kim Lowe Bruce I ailey Harry Hoch
Commissioner Chain rn Commissioner
An Equal Oppor; oily Employer
O(—Q 1 k
MANAGER APPLICATION Office Use
INSERT- FORM 3cEEi1f # .
NEBRASKA LIQUOR CONTROL COMMISSION APR 14 2022
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRASKA Ili; 'is 'u
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 CONTROL C:- .."f„ !
FAX:(402)471-2814
Websitc:www.lcc.ncbraska.gov -
FORM MUST BE COMPLETELY FILLED OUT IN ORDER FOR APPLICATION TO BE
PROCESSED ,
MA1yAGER MUST:
Complete all sections of the application. Be sure it is signed by a member or corporate officer,
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
in processing, this form MUST be included with your application.
4 Provide a copy of one of the following: US birth certificate,naturalization papers or current. US
passport(even if you have provided this before)
V• 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:
V. 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.
i
• Need not answer question#1 of the application .
Spouse who will participate in the business, the spouse must:
• Sign the application
a
• 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
A .
2200004816. ���` 1 nmi ,o.:
Rev.l«iv='
P.igc 1 016
MANAGER APPLICATION office Use
INSERT-FORM.3c RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH , APR 14 2022
PO BOX 95046
LINCOLN.NE 68509-5046 NEBRASKA LIQUOR
PRONE:(402)471-2571 CONTROL COMMlSS$ON
FAX: (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
CorporatioWLC;C 1n ft,rm 5
Name of Corporation/LLC: Gi o d f A4-h irLS I��g� n�•
Prerrrrse«IA�OXr�1' �If3rl�� " .? . . : �r�� �. •- �M�k��.+ ..',_ .� �s,.: �_ �`�� '��. . �.
Liquor License Number: V,3�Q- Class Type A- (if new application leave blank)
Premise Trade Name/DBA: CI O C,COO-h f Y6 Pi ZW\ I n C•
Premise Street Address: 3 I`r I N. in-h C,SIYe-C+
City: Orylabal County: 1)0USIOlc-, Zip Code: (p fbi lg�
Premise Phone Number: C4Q2) 11-1
Premise Email address: YJ. CO}'y?
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.
oX 1 .1 _
SIGNATURE REQ. I Y`CORPORATE'OFFICER/ MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
Ito July 201 K
1'i 2of6
Manager's Information must be completedbeiow PLEA5E,PRINT CLEARLY'
Last Name: Ct C V\ First Name: h..,C_.V1G-t.A fvif:
Home Address: \5 ? C 1 t1'1\7E.,"
City: 1r4 County: 5s:2 7; Zip Code: (. /,; r'J6 'bpCkl
Home Phone Number: Lk
Driver's License Number& State:_
Social Security Number:
Date Of Birth: Place Of Birth: L_CA314 CA\ Cik-CS
Email address: \\I' C J 5o Cox , 1 )e--
Are you married?-If yes;.coinigete qus s informa on((Ly_eri!if'a spousal affidavit has been submitted)
❑ YES OINO
Spouse's information__
a t.�.�- -►a.
Spouses Last Name: J / First Name: till:
Social Security Number:
Driver's License Number& State:
Date Of Birth: Place Of Birth:
APPLICANT&SPOUSE:W IST
S.�1.,>►R a(sE. S?i1E�CE(3)J► 3R HE PAST
AST TEN(1.0)YEARS
APPLCANTf ,
CITY & STATE YEAR YEAR I CITY & STA'1 E YEAR YEAR ('
FROM , TO FROA1 TO
OrieLli a f I\J</ R010 aoa
I - l
r'orm If1?
Ro July 2018
P:tcc 3 of G
TS...i F i=•n. • ..,. TJ '^C.'.^vk ... ,Bk 'w... .e.tr "P.+...�~'»�:.....`
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE I
FROM. TO NUMBER
3 \cl Pce-s0\- ' e__,\\ (gel) Sal
s 6,I it P‘7_7...ck. NA- (k)N'A) T c o -11-6 cq) - s.5d r
Pea ce s4 LLC
I. 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.
M YES C, NO
l f 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
6\c,.e.,, &o(c\ , \b2 0M411t l U C�rY�31e c�
CA,, (0,, -1 `1� Ic1 C 4 t5 �ak\oft_ gtekk rt€c\e r d
?. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or
any other state?.
EYES
IF YES, list the name of the premise(s):
3. Do you, as a manager, qualify under Nebraska Liquor Control Act (§a3-l31.01) and do you intend to
supervise, in person,the management of the business?
P4YES ONO
Form 111i
Rev Ju!v 2018
Page 4 oft,
•
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NLCC Training Certificate Issued: Name on Certificate::
Applicant Name Date Name of program(attach copy of course completion
(mm/YYYY) certificate)
1, [
'(`'\t( c.4ek CV( Lh 5l sck Alco cL\ Ce< 1 4-►«A
•
_ J
*For list of NLCC Certified Training Programs see training
Experience:
Date of
Applicant Name/Job Title Name&Location of Business:
Employment:
i
1 i I
5. Have you enclosed form 147 regarding fingerprints?
EYES '1NO
Form 103
Rev July 201
Page Sof6i
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. . iT.Oft Ei 22SU Y�AITFi C�, SEN1` •
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 §53-1.31.01)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 idea ' :cation record are set forth in Title 28, CFR, 16.34.
Signature of Manager Applicant Signature of Spouse
ACKNOWLEDGEMENT
State of Nebraska
County of e LL �S The foregoing instrument was acknowledged before me this
•
WGka&I CkuArc.k
I date NAME OF PERSON BEING ACKNOWLEDGED
" � Affix Seal
Genera!Nalary•Slate of Nebraska
Notary Public gnature THERESA L ZINGEWAN
My Comm.Exp.March 22,2022.
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 1(h
Rev Ally 2 1 x
Page 6 of 6
PRIVACY ACT STATEMENT/
SUBMISSION OF FINGERPRINTS/ RFCF VF
PAYMENT OF FEES TO.NSP-CID
NEBRASKA LIQUOR CONTROL COMMISSION APR 2 1 z:i
301 CENTENNIAL MALL SOUTH
PO BOX 95046 NEBRAS,•• • .&- iOR
LINCOLN, NE 68509-5046 CONTROL Ctjm;v {SSION
PI IONE:(402)471-2571 ,
FAX:(402)471-2814
Website:wwW.icc.nebraska.gov
THIS 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 REQUIRED FEE TO THE
NEBRASKA STATE PATROL WILLDELAY THE ISSUANCE OF YOUR LIQUOR LICENSE
• Fee payment of S45.25 per person MUST be made DIRECTLY to the Nebraska State Patrol;
It is recommended to make payment through the NSF PayPprt online system at www.ne.govlgornsp
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 Linuor License***
The Nebraska State Patrol-CID Division
3800 NW 12th Street
Lincoln,NE 68521
• Fingerprints taken at NSF LIVESC.AN locations will he forwarded to NSF -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 charge, correction, or updating
a FBI identification record are set forth in Title 28, CFR, 16.34.
*"**Please Submit this form with >our con letcd application to the Liquor Control Commission****•
Trade Name C. .,\ l„\�, c.� - — ;�' _ 2_ t.--' ._ _
Name of Person BeingFine rinted: 1 °i `i` •<\ C�.,= t '`'.
Date of Birth: _ Last 4 SSN:
Date fingerprints were ta. en: \ ..' )1 14.Location where fingerprints were taken: Li`-i t i i t'=`
How was payment made to NSP?
'NSP PAYPORT ®CASH DCHECK SENT TO NSP CK tt_
My fingerprints are already on file with the commission—fingerprints completed for a previous
application l •ss than 2 years ago? YES0
r.
SIGNATURE REQUIRED OF PERSON BEING FINGERPRINTED
FORM 147
REV AUG 2020
4/19/22,2:01 PM Enterprise Mail-MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL HEARING-GODFATHER'S 28033
Carman Johnson (CCIk) <carman. ohnson cit ofomaha.or >
MANAGER'S APPLICATION FOR OMAHA CITY COUNCIL
HEARING - GODFATHER'S 28033
1 message
Carman Johnson (CCIk) Tue, Apr 19, 2022 at 1:56
<Carman.Johnson@cityofomaha.org> PM
To: KSKEY@godfathers.com, Mike church <MC5050@cox.net>
Bcc: "Elizabeth Butler (CCIk)" <elizabeth.butler@cityofomaha.org>, "Kimberly Hoesing
(CCIk)" <kimberly.pulliam@cityofomaha.org>
Good late day
RE: GODFATHER'S PIZZA, INC #28033
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, MAY 17, 2022. 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 MICHAEL J CHURCH. 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
402-444-5263 fax •
Carman.johnson@cityofometha.org
https://mail.google.com/mail/u/0/?ik=cd387c45eb&view=pt&search:nll&permthi.i•=thread-a%3Ar4013282629599396307%7Cmsg-a%3Ar-1201007219... 1/2