RES 2012-0346 - SDL for beer garden at Old Mattress Factory Bar & Grill July 13-14 2012 APPLICAfl4N FOR SPECIAL f ;w a_< <.
DESIGNATED LICENSE w aM. •
NEBRASKA LIQUOR CONTROL COMMISSION `-• s a; }
301 CENTENNIAL MALL SOUTH
PO BOX 95046 .
LINCOLN,NE 68509-5046 kJ/R '>
PHONE:(402)471-2571 :^"s ''.
�_..;is
FAX:(402)471-2814
Website:www.Icc.ne.gov/
RETAIL LICENSE HOLDERS
NON PROFIT APPLICANTS 1-J Non Profit Status (check one that best applies)
Municipal Political Fine Arts Frraternal 'Religious Charitable Public Service
COMPLETE AIL.L'QuESTIONS.
1. Type of alcohol to be served and/or consumed: Beer ,,> Wine . Distilled Spirits
2. Liquor license number and class (i.e. C-55441) 7
(If you're a nonprofit organization leave blank)
3. Licensee name (last, first,), corporate name or limited liability company (LLC) name /
(As it reads on your liquor license)
NAME: F C
STO
AD:I;RESS: Sa>73 t . 5 t-
CITY C5/ f"j '' ZIP a /tom
4. Location where event will be held; name, address, city, county, zip code
BUILDING NAME (-.)Z th7777 ??,0 as e.
ADDRESS: ,/1,`. 63 'e CITY L-')O "
ZIP COUNTY and COUNTY# /t/ -�;n h3
a. Is this location within the city/village limits? YESINO
b. Is this location within the 150' of church, school, hospital or home !/
for aged/indigent or for veterans their wives? YESOO
c. Is this location within 300' of any university or college campus? YES TINTO
•
FORM 108
REV 10/l l
Page 2 of 5
as 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
V 11'',N* VENDOR
i 1
GRILL 1 :
-------] 11.0x1.0
1 1
I i
, 1 1
pm x301 I
, 1 F , 20X45 20X20 20X30 i
1 1 g
i ,
I
rp. !
°„ftf.,A° .
ic-r-V f-4ft4
CA,S S ST ET
5. Date(s) and Tinie(s) of event(no.more than six (6) consecutive days on one application) •
Date Date Date _ Date 3/ 6�., Date �' � ��, Date
Hours Hours c Hours /
Hours Hours Hours
From ' From ..- From From /4'030 From leelemr From
To To To To 2.41E46/ To 2.`t'tP/fA4 To
a. Alternate date:
b. Alternate location:
(Alternate date or location must be specified in local approval)
6. Indicate type of activity to be carried on during event:
Dance ❑Reception li Fund Raiser i Beer Garden ❑Sampling/TastingnOther
7. Description of area to be licensed •5 /91-7a=C I :' ,S Z!7.r- i+
Inside building, dimensions of area to be covered IN FEET x
Outdoor area dimensions of area to be covered IN FEET k'c' ' x o-c
(not square feet or acres)
INCLUDE SKETCH IF OUT"OOR AREA
If outdo r area, how will premises be eiclosed?
Fence type of fence; snow fence a chain link n cattle panel other
Tent
Other explain
•
8. How many attendees do you expect at event? > r.
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)
at1N72.G1+:-; C-0fc 'kc)' cyp'1%rpv=1ic _ m �� csd- `tie pitc 14- Oi eLl
10. Will premises to be covered by license comply with all Nebraska sanitation laws? YES YJ NO
a. Are there separate toilets for both men and women? YES ONO X
11. Where will you be purchasing your alcohol? Wholesaler Retailer Both, BYO
12. Will there be any games of chance operating during the event? YESnNO�
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:
FORM 108
REV 10/11
Page 3 of 5
FORM 108
REV 10/11
Page 4 of 5
V 11'',N* VENDOR
i 1
GRILL 1 :
-------] 11.0x1.0
1 1
I i
, 1 1
pm x301 I
, 1 F , 20X45 20X20 20X30 i
1 1 g
i ,
I
rp. !
°„ftf.,A° .
ic-r-V f-4ft4
CA,S S ST ET
. • ,
.:-_ . . ..
T.D. AMEfrio.E71,,,DE PARK
MIKE FAHEY STREET
• •••• ' !• \ i
- .
. ,
. ,
...
. .. ,
•
1
120x30
,,•. .
i \ .
•
ZSTO'S
, . ___1 , • ,,..., .•
. :
I , ,
• .
`..
. ,
\ \ ,
130X30 • 1
45)05;
...-- \.
...,. .
I L i y
- .
(
i ----1 \
. ;
20X50
.
..
.
0 \ ‘, KD
. ; \ ,
.
,
„
1
., VI
,.... i \\\\
30X60
i
i
sP.,...." .‘
,,•,
\
.,
1 . 1 • \, rat
rA
...7•,::::1___Er= 31 ---.--
0?(I L 7 1
.„,-- I --1 ; i=
...... \ os
p...
• „ ,
\ 1,71t) \ •
0
'V)
1 \ 0
\ 1
. \ 0 V
194)10 SQFT i, \,\ 7," \ „
,
1 . AV AIL*,1;LE \ -
FtiR FUTURE '
. --1
ri t EVEL*P,',':E NT 15 X 15 1
t
1 .
1 " 15 X 15
1 . .
.. •••••• _ .. .....
.,
• 1., / I 1
. ,
.,., 1 .
,-• ____. i .
1 ill II 1 ,
45 Y 6 i:i,1 4 CO X il•.' It -; ,,a,„a V ii n LI_
..::::, ly A,..1.U =ThrTh im . .... 1 ,
11 V IP I •
I •
1.1 011
„,i 1 ,Ert7ggli I i '\
[.. 1 1
. •
ILL 1 :
-------] 11.0x1.0
1 1
I i
, 1 1
pm x301 I
, 1 F , 20X45 20X20 20X30 i
1 1 g
i ,
I
rp. !
°„ftf.,A° .
ic-r-V f-4ft4
CA,S S ST ET
- -- FOOD FOOD FOOD I FOOD j
1.--- — VENDOR VENDOR VENDOR aI VENDOR
_ .
V.it PDr.Er. i I -" --J
, ,
, .
1
__,
I P tRTYl i.a t EA I I FOOD FOOD MATT I t__ I IL
ni I I J I VENDOR VENDOR 6LITCB-9ENV
-ill Li
r I I f' -i
I
,A - —
•
g' ` 1
FOOD FODO FOOD FDOO I i -�
Ti VENDOR VENDOR VENDOR)VENDORI (
® W ®
3`s �0 \\ / —1
- l_L' . USA I
30t 30 % � g
I :— r
I COMMAND I I- �._L
.[� m
CENTER !N
I ! i 1 _ I
Hii
I - -
I t
f1`I •I roar„,7-1;117..,omea j 1
I 1 ( -I
UTILITIES AN D STORAGE AREA I
F CT •^RY ---=,
I 1
;Y FOOD 20X20 20X20 I
•
GI ii• ILL I -- ------ —i ! 1OX10
I
3 I
!loxMI
E I 20X45 20X20 20X30
i
..., � �--y-�,—� A .�::� - —ir—
CABS STREET
i, \,\ 7," \ „
,
1 . AV AIL*,1;LE \ -
FtiR FUTURE '
. --1
ri t EVEL*P,',':E NT 15 X 15 1
t
1 .
1 " 15 X 15
1 . .
.. •••••• _ .. .....
.,
• 1., / I 1
. ,
.,., 1 .
,-• ____. i .
1 ill II 1 ,
45 Y 6 i:i,1 4 CO X il•.' It -; ,,a,„a V ii n LI_
..::::, ly A,..1.U =ThrTh im . .... 1 ,
11 V IP I •
I •
1.1 011
„,i 1 ,Ert7ggli I i '\
[.. 1 1
. •
ILL 1 :
-------] 11.0x1.0
1 1
I i
, 1 1
pm x301 I
, 1 F , 20X45 20X20 20X30 i
1 1 g
i ,
I
rp. !
°„ftf.,A° .
ic-r-V f-4ft4
CA,S S ST ET
•
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.
d.
Print name of Event Supervisor y iet2 a:O 0
Signature of Event Supervisor ' ;, a b; -
Phone of Event Supervisor: Before 9C - 14-9-. '?J 9L During 6(G`2' _ 91--c/Z
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.
Ide
sign
"g‘• X'
Authorized Representative/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 10/11
Page 4 of 5
-------] 11.0x1.0
1 1
I i
, 1 1
pm x301 I
, 1 F , 20X45 20X20 20X30 i
1 1 g
i ,
I
rp. !
°„ftf.,A° .
ic-r-V f-4ft4
CA,S S ST ET
4...N. ts4. 4
.1.0 ,, t, i .. 4 c, II) sl> ,7:3 0 0
2 0\\i„ . k ‘ „V° ki) .r/i . 0 ,-, c,-;) . - -
$ . ,-.•
N 4. . ..... w pa
0 0_. cD 5
k.N D w \
S.. N p, N.) 0 cn 'Eli ‘ \
W
" C ` \ • % p r p
,\ Cb B O k'N(i
� %„i q. h �
NV % kl- p o
k 4 \ ,..,_ CD "
„,!...‘, _ ,.., "' -
, Okt a\s.
r
" k, N kkNik, \
0 CD
\ N,, k :AIN%
a . \ i '-.\,
1 % \,Z.\131 k
q ,14,4
, ci
,b, tk,
ti,% 4 N \ , ,, ° '' ' ! LIT'jo4
‘ ,