RES 2012-1036 - SDL for dance at Rehab Lounge August 10 2012 t
1
APPLICATION FOR SPECIAL
DESIGNATED LICENSE
NEBRASKA LIQUOR CONTROL COMMISSION
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.ne.gov/
DO YOU NEED POSTERS? YES 0 NO
RETAIL LICENSE HOLDERS 0
NON PROFIT APPLICANTS°
Non Profit Status (check one that best applies)
Municipal° Political° Fine Arts° Fraternal°Religious° Charitable° Public Service°
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Beer J1 Wine n Distilled Spirits Fi
2. Liquor license number and class(i.e.C-55441)
(If you're a nonprofit organization leave blank) ( I 0
3. Licensee name(last,first,),corporate name or limited liability company(LLC)name
(As it reads on your liquor license)
NAME: /f C/A dl l,,. _6 A-, I t ( .4/
ADDRESS:l^ (
CITY ),A,1 eV\ ZIP i SI z`4
4. Location where event will be held; name,address,city,county,zip code
BUILDING NAMEGL‘J.Th
ADDRESS: d,r.;\S S. \A)° � CITY CDr-Nc\tic,
ZIP . ( Li 14 COUNTY and CSC
a. Is this location within the city/village limits? YES Mil 0E1
b. Is this location within the 150' of church,school,hospital or home
for aged/indigent or for veterans and/or wives? YESnVO n
c. Is this location within 300' of any university or college campus? YES[NOn
FORM 108
REV 5/12
• Page 2 of 5
y'.
' 11. Retailer: Will you be purchasing your alcohol from a wholesaler? YES n NO n
Non-Profit: Where will you be purchasing your alcohol?
Wholesaler Retailer 0 Both 0 BYO
(includes wineries)
12. Will there b any games of chance operating during the event?YESENO�✓
If so,describe activity
NOTE:Only games of chance approved by the Department of Revenue,Charitable Gaming Division are permitted. All other forms of
gambling are prohibited by State Law: There are no exceptions for Non Profit Organizations or any events raising funds for a charity.
This is only an application for a Special Designated License under the Liquor Control Act and is not a gambling permit application.
13. Any other information or requests for exemptions:
14. Name and telephone number/cell phone number of immediate supervisor. This person will be at
the location of the event when it occurs, able to answer any questions from Commission and/or law
enforcement before and during the event,and who will be responsible for ensuring that any applicable
laws,ordinances,rules and regulations are adhered to. PLEASE PRINT LEGIBLY
Print name of Event Supervisor ----Ct, - '•
.\, '\
Signature of Event Supervisor
Phone of Event Supervisor: Be e ),2". , ,5\Gi?t t During 4`L \`� Z.� 1 1
n ', w
Consent of Authorized Repre'sentati\'d/Applicant •
15. I declare that I am the authorized representative of the above named license applicant and that the
statements made on this application are true to the best of my knowledge and belief. I also consent to
an investigation of my background including all records of every kind including police records. I
agree to waive any rights or causes of action against the Nebraska Liquor Control Commission, the
Nebraska State Patrol or any other individual releasing said information to the Liquor Control
Commission or the Nebraska State Patrol. I further declare that the license applied for will not be
used by any other person, group, organization or corporation for profit or not for profit and that the
event will be supervised by persons directly responsible to the holder of this Special Designated
License.
sign ii -
here
Aldo ' ed Repre a e/Applicant Title Date
Print Name
This individual must be listed on the application as an officer or stockholder unless a letter has been filed appointing an individual
as the catering manager allowing them to sign all SDL applications.
The law requires that no special designated license provided for by this section shall be issued by the Commission without the approval of the
local governing body. For the purposes of this section,the local governing body shall be the city or village within which the particular place for
which the special designated license is requested is located,or if such place is not within the corporate limits of a city or village,then the local
governing body shall be the county within which the place for which the special designated license is requested is located.
FORM 108
REV 5/12
Page 4 of 5
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'Johnson, Carman (CCIk)
'From: Tommy Nguyen <tommy@rehabomaha.com>
Sent: Thursday, July 26, 2012 4:20 PM
To: Johnson, Carman (CCIk)
Subject: Re: TITLE COMPANIES THAT WILL COMPLETE THE 500 FOOT SEARCH
Carmen,
Please change my SDL sqft to 69 x 89 to the southeast corner of parking lot. Same exact measurement from the
last SDL.
Thank you
Tommy Nguyen
On Wed, Jul 25, 2012 at 1:11 PM, Johnson, Carman(CCIk) <Carman.Johnson@ci.omaha.ne.us> wrote:
Please notify me if you cannot access the attachment or 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 •
Cjoluison3@ci.omaha.ne.us
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man(CCIk) <Carman.Johnson@ci.omaha.ne.us> wrote:
Please notify me if you cannot access the attachment or 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 •
Cjoluison3@ci.omaha.ne.us
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