RES 2002-1724 - Appoint Scott D Roberts manager of Pizza Hut •
STATE OF NEBRASK , ..
NEBRASICA LIQUOR CONTROL COMMISSION
=04.� ,��o;��, °2 Forrest D. Chapman
" �;yS JUL rim S Executive Director
•
Q)its
ii"1 39 301 Centennial Mall South,5th Floor
IJ P.O. Box 95046
- m4y� L'(� v Lincoln,Nebraska 68509-5046
8I;i�, O M (- -tt?A Phone(402)471-2571
H4. NEnn Fax(402)471-2814
• SKI TRS USER 800 833-7352(TTY)
Mike Johanns web address:http://www.nol.org/home/NLCC/
Governor •
• July 10, 2002
City Clerk
Omaha/Douglas Civic Center
1819 Farnam LC-1
Omaha NE 68117
•
RE: • Manager Application Submittal •
Dear Sir/Madam:
The enclosed Application for Manager is being submitted by Peak Interests LLC DBA
Pizza Hut located at 4925 "L" Street, Omaha, NE 68117 (Douglas County) which holds a Class J
License #35986 the applicant's name is Scott D. Roberts.
Please present this application to your City/County Council and return to us the results of
the action taken. If you have any questions or comments,please give me a call.
Sincerely,
••
elle Petersen
Licensing Division
Enclosure
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•
•
Rhonda R. Flower Bob Logsdon R.L. (Dick)Coyne
Commissioner Chairman Commissioner
An Equal Opportunity/Affirmative Action Employer
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Printed with soy ink on recycled paper
Loca.I
C P-At
• Application for Corporate Mana
*Must Be A Nebraska Resident* NECEIVED
Return to: Nebraska Liquor Control Commission,PaBox 95046 .
JUL 217
301 Centennial Mall So.,Lincoln NE 68509 -
Phone:(402)471-2571 Fax (402)471-2814 Web address: http://nolorg/home/NLCC NEBRAsica ,
--.5
UNTRO
fStoo5AWt9Rc ;ISEMIMM-gf9AgaaOdeZ,IkttvMg'IL,ih%W$V't.-d,g-,P1-'''''s,'
NAME OF LICENSED CORPORATION '.- - • ' CLASS&LICENSE NUMBER
Peak Interests L.L:Caba Pizza Hut Class J #35986 be_.
TRADE NAME OF LICENSED PREMISE '
Pizza Hut
, .
STREET ADDRESS OF LICENSED PREMISE CITY COUNTY ZIP CODE
4925 ,"L" Street Omaha Dthiglas` 68117
11--- De-r-
On behallOf the corporation,Idesignate this mdlvi s'corporal'manager.,
. , .
Signature of Corporate President/CEO: :
APPLIA JNFORMATION (MUST BE 21 OR OVER)
:1*41M441$614'444"44UH44: 1;*
NAME(LAST,MIDDLE,FIRST,MAIDEN) SEX SOCIAL SECURITY NUMBER DATE OF BIRTH PLACE OF BIRTH
Roberts, Scott, Dduglas, -: 4-8-74 Denver, CO
HOME STREET ADDRESS CITY COUNTY STATE ZIP CODE
5816 South. 94th Plaza, Apt. #9 Omaha Douglas NE 68127
HOME TELEPHONE NUMBER BUSINESS TELEPHONE NUMBER DRIVERS LICENSE NUMBER&STATE
4,0 5,.9 2-864,3 , -(402.-'292.L621 2 ' NE H1 2066842.
A 044.-1ar•fr*
Nritb-OF ',Lc 41: OpEDINDIçAFE
1,bve ,f-Av -*4;w •§6*ffric
FULL NAME(LAST,FIRST,MIDDLE,MAI N) , SOCIAL SECURITY NUMBER DRIVERS LICENSE NUMBER
Not Applicable
, le4 771 p &STATE
„
1" I —
. . .
DA . - PLACE OF BIRTH: - • '
I. READ CAREFULLY-ANSWER FULLY AND ACCURATELY Has,anyone who is a party to this application or their spouse
. .
ever been convicted of or pled guilty to any criminal charge? Criminal charge means any charge alleging a violation of a Federal.State
or local law or ordinance. List the nature of the charge,where the charge occurred and the year and month of the conviction or guilty
plea. Also list any pending charges at this time.
•
2. Have you or your spouse ever made application for any liquor license or manager for any liquor license? IF YES,for what premise give
license number and date.
DYES ONO
3. Have you or your spouse ever made a compromise settlement for violation of such laws?
OYES ONO
FORM 354013
REV. 11/99
PAGE 1
4. Do you,as a manager,have all the qualifications required by any person entitled to hold a Nebraska Liquor License?
Nebraska Liquor Control Act(§53-131.01) .
RIVES ONO
5. Have you filed fingerprint cards and proper fees with this application? -
OYES ONO . ..In .Process...:". .:. , .. .. ., _ ,..
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APPLICANT:CITY&STATE YEAR SPOUSE:CITY&STATE YEAR
.._ FROM TO.. FROM . . ... . . TO . .. ..
Omaha, Nebraska 92 Pres
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4 - y� Rhr `�' ''o :,,,. ;�_.�yw _., 4 ° y,1441 m. �z ,.
it?t
YEAR NAME OF EMPLOYER NAME OF SUPERVISOR:'" TELEPHONE NUMBER
FROM TO
99 Pres Peak Interests L L C MkeOra'ciorl' (402 ) .592-5591
98 99 J S Ventures (Applebee' s) Sean Houd (.402.)•::339-4359
4,+IF I V z r
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STATE OF:.NEBPASKA )
• ) SS _ •
COUNTY OF
The above mdividual(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'ttue If any false Statement is made in any part of this
application,ilia applicants)shalt be deemed guilty of perjury;and subject to penalties provided by law (See::§53 131:01))•Nebraskatig or 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,an affidavit 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 and inaccurate
/ f
/'i111, •
• Si if Applicant Signature of Spouse(if applicable) -
Subs d in my presence and sworn to before me this, .4 Subscribed in m day , - y presence and sworn'fo before me this
day of
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el--e,/2 Chid
Notary Signa reSea�I / Gv
. ... Notary Signature&Seal
BRENDA M. CHALUPA
General Notary-State of Nebraska
My Commission Expires Oct.29,2004
FORM 35-4013
REV.11/99
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