RES 2012-1094 - SDL for party at My Place September 1 2012 a'
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.lec.ne.gov/
•
DO YOU NEED POSTERS? YES NO
RETAIL LICENSE HOLDERS
NON PROFIT APPLICANTS Q
Non Profit Status (check one that best applies)
Municipal° Political 0 Fine Arts° Fraternal° Religious() Charitable° Public Service
COMPLETE ALL QUESTIONS •
1. Type of alcohol to be served and/or consumed: Beer °*Wine 7Distilled Spirits 2-
2. Liquor license number and class (i.e. C-55441) • `' fj j
(If you're a nonprofit organization leave blank) 1 �rl
3. Licensee name (last, first,), corporate name or limited liability company (LLC) name
(As it reads on your liquor license)
•
NAME: P1 (l j p •
I i ��
L9
c,
ADDRESS: ? ? •7 I. ✓ �C,.l
.. L57 ' ''
CITY LC-247•14: 'i ZIP f 1 I
•
4. Location where event will be held; name, address, city, county, zip code
i::UILDINO NAME f L C.o c
C �' r�
ADDRESS: c0. r. � CIITY �' ( h
ZIP O 1 U COUNTY and COUNTY # �u�;) �t s Ct
a. Is this location within the city/village limits? YES)NO
b. Is this location within the 150' of church, school, hospital or home
for aged/indigent or for veterans and/or wives? YESEINOFF
c. Is this location within 300' of any university or college campus? YESIO
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FORM 108 •
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Page 2 of 5
a 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 ,� Owner 07/24/2012
here Ac.
Authori d Representative/Applicant Title Date
William Baburek
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
of 5
5. Date(s) and Time(s) of event(no more than six(6) consecutive days on one application)
'Date ,.-'\Date /' Date Date Date Date
4)$ / N
Ho°ls,. 'ours / Hou Houuss Hours Hours
Fr From F.pm From From From
it i P B'4 ‘ ) fV
T j � To // To To To
a. Alternate date: 9 f Z- cs,-p•-e/ 9/ / /iz
_ • `irfee ' ;,--L-
b. Alternate location: 7 -
(A➢ternnate date or location must be specified in local approval)
6. Indicate type of activity to be carried on during event:
Dance Reception °Fund Raiser QBee Gardenampling/Tasting
0Othercl)iC C (1J_ a(
,C. .,1f
7. Description of area to be licensed
Inside building, dimensions of area to be covered IN FEET x
(not square feet or acres)
*Outdoor area dimensions of area to be covered IN FEET -2021 x f: (,)
*SKETCH IF OUTDOOR AREA (or attach Copy of sketch)
-7:5 iN Al er ? •
If outdoor area, how will premises be enclosed?
Fence; snow fence' ' chain link cattle panels other
le ent
8. How many attendees do you expect at event? /00
9. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from
�
obtaining alcohol beverages. (Attach separate sheet if needed)
j
{uf''// & i( y (G L? 'ice 4' / /`Z/'J l / ;-oil ( do°
10. Will premises to be covered by license comply with all Nebraska sanitation laws? YESTO
a. Are there separate toilets for both men and women?YES ''NO[
al 1' C., IA i i I CA/0 lAil') FORM
F(EV 5108
Page 3 of 5
tate 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 ,� Owner 07/24/2012
here Ac.
Authori d Representative/Applicant Title Date
William Baburek
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
of 5
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� Owner 07/24/2012
here Ac.
Authori d Representative/Applicant Title Date
William Baburek
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
of 5
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11. I':etai➢er: Will you be purchasing your alcohol from a wholesaler? YES 1 NO
Non-Profit: Where will you be purchasing your alcohol?
Wholesaler Retailer 0 Both C BYO()
• (includes wineries)
12. Will there be any games of chance operating during the event?.YESO[
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:
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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
Signature of Event Supervisor �° �� t• ����.,r�_� :L .;
Phone of Event Supervisor: Before L/t) ) - e./03--` QCici During 1/02 -40-,3-gOciCf
Consent of Authorized Representative/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 myy 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
here
Authorized Representative/Applicant Title Date
•
Ee( ske & k-h.
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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