RES 2018-0327 - Old Chicago appoints Steven E Roy manager of class I liq lic loc E-MAILED TO NLCC 7—1 1"a
- - 2 STATE OF NEBRASKA
it a . "ter ' °s Pete Ricketts • , NEBRASKA LIQUOR CONTROL COMMISSION
t o k} Governor zp 1 iM Lf �F 2: Hobert B. Rupe
� Executive Director
�R�rtiR� � V F 301 Centennial Mall South,5th Floor
C I P.O.Box 95046
jAc
Lincoln,Nebraska 68509-5046
i H N F. L.t;/. r, A Phone(402)471 2571
Fax(402)471-2814 or(402)471-2374
TRS USER 800 833-7352(TTY)
Web address http://www.lcc.nebraska.gov/
•
3/14/2018
•
• To: CITY CLERK OF OMAHA
Email: CARMAN.JOHNSON@CITYOFOMAHA.ORG •
Manager Name: STEVEN E ROY
Licensee Name: WADSWORTH OLD CHICAGO INC
Licensee Trade Name: OLD CHICAGO
License Number: 1-046468
'Due Date: Monday, April 30, 2018
I have attached a copy of a new manager application that was submitted to the Nebraska Liquor
• Control Commission. Please complete the following information below to indicate your
recommendation. Send back to TRACY at tracy.burmeister@nebraska.gov or fax to 402-471-
2814. If you have questions concerning this matter, please contact our office at 402-471-2572.
NK APPROVED
NO LOCAL RECOMMENDATION
DENIED
COMMENTS (YOU MAY ATTACH MINUTES AND/OR ADDITIONAL NOTES): • •
I 4 s # 7 Aiauti / r 3 ?oiY
•
•
Clerk Signature: _
Date: 21'/H
Janice M.Wiebusch Robert Batt
commissioner Chairman 1800003382
An/iyua/Opporlunilp Employer
•
MANAGER APPLICATION Office use
INSERT-FORM3c RECEIVED
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH tAAR 1 4 2018
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571 NEBRASKA LIQUOR
FAX: )471-2814 C(TNTROL COMMISSION
Website:ite:www.lcc.nebraska.gov
MUST BE:
1 Citizen of the United States. 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
I 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
7 .er
• �� tii�"n/,i� LL.0�0 .._,.,.,.:�,..�fs. ?'_` �'?..i.�.,.��- .:+ t�sse. ^,.r.a .��t.,...�,.:.,_..��r.._,_. . ...,.•r,�_ _ ._..1 �a
Name of Corporation/LLC:
Wadsworth Old Chicago, Inc.
5'410s?fxlh �� 4_... .._. :� .. ._t...,«�a s=.f + :: . ,f;ra_ a... F.. A. ' . ....rwk
Liquor License Number: 46468 Class Type (if new applteatme leave blank)
Premise Trade Name/DBA:Old Chicago
Premise Street Address:425 N 78th St
City: County:county:Douglas zip code:68114
Premise Phone Number:(303) 664-4083
Premise Email address:cass@oldchicago.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 CORPORATE;OFFICER/:MANAGING MEMBER
(Faxed signatures are acceptable)
Form 103
Rev Jan 2018
Page 2 of 6
iStanag ils_iaiiiinafioa m ifiaomplaaTielow t7HairtIi - CLEARLYcry7 _',J
Last Name: Roy S� First Name: S-�-eve�I Ml: E
�
Home Address: 3 6 0 1 0 n GS , A'p F 3 17
City: bl'h0.tiu, County: 1)0149]a5 Zip Code: 69I05-
Home Phone Number: 17 S l - 'ip-q- •7 g S 7
Driver's License Number&State:_ite
Social Security Number: T� !, - - - -
/ •
Date Of Birth: .! . , -- Place Of Birth: St. LOWS P k( /11N
Email address: oy Old 6104-010• c(V
e ,Ou�'1ma�'led?.Ifjr'escoiimit'eteps"pouses"�informaifion(Even;ift`a`ssp ii"sala `idaitlibce"nbmittedf' :I
❑YES Ogj NO
Spouses Last Name: First Name: MI:
Social Security Number:
Driver's License Number&State: -
Date Of Birth: Place Of Birth:
T '•P CB 4&SPOIKJ. ST- iiST 1• ENC1+3 S `.0 it. tl• 7i1. :��p 3' • :. :; ;
•• t A.NtTYEAR EAR. :x .. YZ}•yl-l� -._;L.i�•L'�'n.� e��.l_v i..yA o 0 a w' / ..13`�ti.a:r.-a.�-...w.s'{`i��19C�i�a.Ew.^i:,
CITY&STATE FROM YTO CITY&STATE YEAR
YEAR
f aveiltvilit ,NG ?014 do+s
Co kurhb)AisG ?015' 0,o)6
jhctQcm Jllc IUL. ?-01 I go1s
eLarrbaryI NL 0-01 1-1 001-J
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gt oo�lnf�n� NI N arJo$ 2O�'i
Form 103
Rev Jan 20111
Page 3 of 6
A IS:CAST. • , EMPLO : { t
YEAR
NAME OF EMPLOYER NAME OF SUPERVISOR TELEPHONE
FROM TO NUMBER
;-006 Nub 0(d Ncelo S coW it/41 Soya 1 o -y 3 3-J99s
2,00b aoo$ kppit.Bees eta 1 , NE s t j-c yR -6 000
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 tugging 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.
21 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
5 FCV e 120V G/ .o c 01610 14411,JU_ DU 614111-t
2. Have you or your spouse ever been approved or made application for a liquor license in Nebraska or.
any other state?
AYES ONO
IF YES,list the name of the premise(s):
old bk i'-a yv, C 6.e.rfe"q.e, N C.
3. Do you,as a manager,qualify under Nebraska Liquor Control Act(653-131.01)and do you intend to
supervise,in person,the management of the business?
AYES ONO
Form 103
Rev Jan 2018
Page 4 of 6
4. List the alcohol related training and/or experience(when and where)of the person making application.
*NLCC Training Certificate Issued: 5el"Vsa Name on Certificate: S '" e I` /
Date
Applicant Name (mm/yyyy) Name of program(attach copy of course completion certificate)
Sklre. RP( W?-vii Servs j-e klka&o(
*For list of NLCC Certified Training Programs see training
Experience:
Applicant Name/Job Title Date of Name&Location of Business:
Employment:
Sieve Ray - 9&„c47,1 ' '"iec ?-000-fres4it -Vtw)o..s Loc 4 vAs
5. Have you enclosed form 147 regarding fingerprints?
OYES ONO
Fomi103
Rev Jan 2018
Page 5 of 6
1Vif PERSONAIMATE-MTWE1+Td'� F.4 t TWAT
•
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-I31.01)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 Not/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
contained in FBI identification record. The procedures for obtaining a change, correction, or updating an
FBI identification record are set f rth in Title 28, CFR, 16.39.
ignature of Manager Applicant Signature of Spouse
/ • ACKNOWLEDGEMENT
State of N (,(
County of CIS GIB d The foregoing instrument was acknowledged before me this
a by
date NAME F PERtj BEING ACKNOIVLEDGED
w Affix Set
Notary Public signature STEPHANIE L DEVINE
NOTARY PUBLIC
STATE OF COLORADO
NARY Ig.it 1997.01
MY COMMISSION EXPIRES 10/20/2021
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 Ian 201$
Page 6 or6
RECEIVED
SUBMISSION OF FINGERPRINTS/
ATE RECEIVED
PAYMENT OF FEES TO NSP-CID DATE
1 4 2018
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046 CONTROL ;mot s:: ;r; " N
LINCOLN,NE 68509-5046
PHONE: (402)471-2571 Office Use Only
FAX: (402)471-2814
Website: www.lcc.nebraska.gov Class:.______ License#:
Applicant Name: Wadsworth Old Chicago, Inc.
(Corporation,LLC,Partnership or Individual)
Trade Name: Old Chicago
(Doing Business As)
303-664-4083 sdevine@cwrestaurants.com
Phone Number Contact E-mail Address
DIRECTIONS FOR SUBMITTING FINGERPRINTS AND FEE PAYMENTS:
•
• FAILURE TO FILE FINGERPRINT CARDS AND PAY THE REQUIRED PROCESSING FEE TO
THE NEBRASKA STATE PATROL WILL DELAY THE ISSUANCE OF YOUR LIQUOR
LICENSE.
• See Application Requirement Guide for listing of Fingerprint Requirements found on our website under
"Licensing"tab in"Applicant Guidlines".
• DO NOT send fee payments to the NLCC—fees MUST be paid directly to NSP.
• 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 12th Street
Lincoln,NE 68521
• Fingerprints taken at NSP 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 will be released to the applicants;
Fingerprint cards should be submitted with the application.
Please complete information on the following pages for EACH person fingerprinted.
FORM 147
REVJAN 2018
PAGE 1
I. Name:Steven Roy Date of Birth: -- Last 4 SSN:
Date fingerprints were taken: 2/6/1 8 Location where fingerprints were taken:Lincoln
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 0
2. Name: 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 0
3. Name: 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 0
4. Name: 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 0
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.
I hereby certify that fees of$45.25 per person have been submitted directly to the Nebraska State Patrol—CID
office. The undersigned certifies on behalf of the Corporation,LLC,Partnership or Licensee that it is understood
that a misrepresentation of fact is cause for rejection of this application or suspension,cancellation or revocation of
any license issued.
'v V\ Title: r;'Q�(7 Y—
Name(Print): 4 U 1 (, l
Yv `ilotte I
Signature: Af()
Date: p�1 I'M
FORM 147
REV JAN 2018 •
PAGE 2
City of Omaha, fAfebras&a ,��s
1819 Farnam —Suite LC 1 z �f
rOM 111
Omaha, Nebraska 68183-0112 0 in, a
Elizabeth Butler (402) � ,
444-5550 `.�
City Clerk FAX (402) 444-5263 944' '4
D FEBR
March 27, 2018
Wadsworth Old Chicago, Inc. Application to appoint Steven E. Roy
Dba"Old Chicago" manager of your present Class "I"Liquor
425 North 78th Street License location
Omaha,NE 68114
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to
appoint a manager to the liquor license has been set for April 10, 2018 . The City Council
Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic Center,
1819 Farnam Street, Omaha,Nebraska. City Council Liquor Rule No. 6 states, "Each applicant
or his/her representative for any type of license shall be personally present in the Council
Chambers, in order that the Council may make inquiries, on the date of public hearing of the
application for said license". Failure to be present at this Council Meeting is grounds to
recommend denial of your application to the Nebraska Liquor Control Commission.
Sincerely yours,
Elizabeth Butler
City Clerk
EB:clj
�NIAHA, N
City of Omaha, Nebraska 0
1819 Farnam —Suite LC 1 cM tit
Omaha, Nebraska 681 83-01 1 2sr _ k ,
Elizabeth Butler (402) 444-5550 �+`
City Clerk FAX (402) 444-5263 D,p�'
TFD FEV%v
March 27, 2018
Steven E. Roy Application to be appointed manager of the present
3601 Jones Street,Apt 317 Class"I"Liquor License location for Wadsworth Old
Omaha,NE 68105 Chicago, Inc., dba"Old Chicago", 425 North 78th
Street
Dear Liquor License Manager Applicant:
This letter is notification that a hearing before the Omaha City Council on your application to be
appointed manager of the liquor license has been set for April 10, 2018 . The City
Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic
Center, 1819 Famam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states, "Each
applicant or his/her representative for any type of license shall be personally present in the
Council Chambers, in order that the Council may make inquiries, on the date of public hearing
of the application for said license". Failure to be present at this Council Meeting is grounds to
recommend denial of your application to the Nebraska Liquor Control Commission.
Sincerely yours,
Elizabeth Butler
City Clerk
EB:clj