RES 2012-0344 - SDL for beer garden at Old Mattress Factory Bar & Grill July 4 2012 APPLICATION FOR SPECIAL F?Fr : i rri
DESIGNATED LICENSE •
I FEB -8 p"
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NEBRASKA LIQUOR CONTROL COMMISSION f 1 ,2:
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046 '�rz ... -, it,.. q ,
PHONE:(402)471-2571 3 i:i .1 lei y
FAX:(402)471-2814
Website:www.lcc.ne.gov/
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RETAIL LICENSE HOLDERS
NON PROFIT APPLICANTS_Non Profit Status (check one that best applies)
MunicipalnPolitical[Fine Arts FraternalnReligiousnCharitable Public Service
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Beer 21 Wine 7 Distilled Spirits
2. Liquor license number and class (i.e. C-55441) t� .. 7 S
(If you're a nonprofit organization leave blank)
3. Licensee name (last, first), corporate name or limited liability company (L C) name
(As it reads on your liquor license)
NAME:
ADDRESS:' /1l• %:J 5
CITY 0/4/4-M ZIP 6 er/'g a
4. Location where event will be held; name, address, city, county, zip code
BUILDING NAME ()IA J�''if�iTL�S' /7i'c° iok y �A;4 C...
ADDRESS: ; /ia. 13 :�'/ CITY "1
ZIP 6 gf02 COUNTY and COUNTY # JtJ& /45
a. Is this location within the city/village limits? YESNO •
b. Is this location within the 150' of church, school, hospital or home �-n
for aged/indigent or for veterans their wives? YESI_lNCE
c. Is this location within 300' of any university or college campus? YESnv0
FORM 108
REV 10/11
Page 2 of 5
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 villagc,thcn the local governing body shall be the county within which the place for which the special
designated license is requested is located.
REV 6/09 •Page 3
s 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.
1/4 14--S j'c� (Ali A'iO 1, i'i tcJi ,ci
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5. Date(s)and Time(s) of event(no more than six (6) consecutive days on one application)
Date /��/Z Date Date Date Date Date
•
Hours Hours Hours Hours ' " Hours .' Hours
From /t.bC 4'1 From I From_ — -- From From_ From
To 2'o(- ,4i11 To To To To ' To
a. Alternate date:
b. Alternate location:
(Alternate date or location must be specified in local approval)
6. Indicate type of activit to be carried on during event:
Dance ❑Reception Fund Raiser IBeer Garden ❑Sampling/TastingOOther
7. Description of area to be licensed -5&/9i/ictiQ4 S ei ci+
Inside building, dimensions of area-to be covered IN FEET x
Outdoor area dimensions of area to be covered IN FEET (tau x 'f ,
(not square feet or acres)
INCLUDE SKETCH IF OUTDOOR AREA
If outdo r area, how will premises be closed?
Fence type of fence; snow fence ai chain link❑cattle panel❑other
Tent
Other explain
8. How many attendees do you expect at event? .V*
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)
At 7/a`NS aria G/K kV /41-61,7044k3 L , :peg! v1=the ivitc 1c eicew
/, 2is"rMvAS . OFF Alf I y Fabin 711 L. iU. d//Z./cnTL' , cti 7/0 CIA/
•
10. Will premises to be covered by license comply with all Nebraska sanitation laws? YES FT NOn
a. Are there separate toilets for both men and women? YES NO y
11. Where will you be purchasing your alcohol? Wholesaler 14 Retailer Both LI BYO ❑
12. Will there be any games of chance operating during the event? YESOIY1
If so, describe activity
NOTE: Only games of chance approved by the Department of Revenue, Charitable Gaming Division are permitted. Al]
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:
4 5 /.L / L/4` rJ %.279-,4 )
FORM 108
REV 10/11
Page 3 of 5
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.
1/4 14--S j'c� (Ali A'iO 1, i'i tcJi ,ci
REV 6/09 Page 2
• i
. ..._.. ___ . •
T.D. AMERITRADE PARK
MIKE FAHEY STREET
; \
1 „...,
; 1 V
I____ I
20X301
\ .
ZESTOS
,.._______.__:_____L____ • .
••
30X30 1 ,
. \
• ,i5x,1 .- , ,
, .
20X50 1 \ 0_,_
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, 0.
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...
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hal
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\ semi
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(1)
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30X60 ...
1 73
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1 1 rn
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19000 SQFT !
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AVAILABLE '' \
FOR FUTURE ,
1
DEVELOPMENT
15 15
......
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r 1-i 7 1
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fl, rill
45X60 ,
, ,..
, .
40 X 60 30X40
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A ti _LI Plg'vi iI 1
.,, • i .
•
ler 14 Retailer Both LI BYO ❑
12. Will there be any games of chance operating during the event? YESOIY1
If so, describe activity
NOTE: Only games of chance approved by the Department of Revenue, Charitable Gaming Division are permitted. Al]
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:
4 5 /.L / L/4` rJ %.279-,4 )
FORM 108
REV 10/11
Page 3 of 5
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.
1/4 14--S j'c� (Ali A'iO 1, i'i tcJi ,ci
REV 6/09 Page 2
•
— i FOOD FOOD FOOD 1 FOOD I
----—
1 � VENDOR VENDOR VENDOR I VENDOR I .
V.I.P. REA L____ I— .
•
11
30X60 1 li PRIVATE I1
- I FOOD FOOD MATT !
_ PARTY AREA I
m ! I 2 I VENDOR VENDOR KITCHEN 'i,
f.
N - i�.1
m I m
PY7iJ ,w {A
X l OW • 7 . ,
-I:maCA x U I- (.1pi E O "�
IT VENDOR VENDOR VENDDORNENDOR! I
E I ( BAR ) a1— in I
1 I ! z / c z 7, I
W I
30X30
1 \ / VHN
I ' l 0
UI� N I
I
30X30 . a i oac z X
CO / uIo W- N
— a N 1
COMMAND�I I �,,.. - pe Z Tr X 1
CENTER'- 1 I W
— U ~ N
II I _
I' r
THE OLD UTILITIES AND STORAGE AREA I STAGE
MATTRESS _ _ ) I 20X45
FACTORY
I I
FOOD
BAR AND VENDOR 20X20 20X20 _____
GRILL I .__-- _I 110X10
1
20X45 20X20 20X30 iio x 3o
CASS STREET
0
:!• illi ,
A ti _LI Plg'vi iI 1
.,, • i .
•
ler 14 Retailer Both LI BYO ❑
12. Will there be any games of chance operating during the event? YESOIY1
If so, describe activity
NOTE: Only games of chance approved by the Department of Revenue, Charitable Gaming Division are permitted. Al]
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:
4 5 /.L / L/4` rJ %.279-,4 )
FORM 108
REV 10/11
Page 3 of 5
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.
1/4 14--S j'c� (Ali A'iO 1, i'i tcJi ,ci
REV 6/09 Page 2
i
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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.
Print name of Event Supervisor s/ i2 LI jot
Signature of Event Supervisor ()al
Phone of Event Supervisor: Before 9()�- S'1 `1J9l_ During t,1UZ. —CS = Ct'S 4
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 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 •
here � �
Authorized Representative/Applicant Title Date
ime,e Q A) #`3lC. i4
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 10/11
Page 4 of 5
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.
1/4 14--S j'c� (Ali A'iO 1, i'i tcJi ,ci
REV 6/09 Page 2
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