RES 2011-0603 - SDL for beer garden at Welcome Inn Tavern June 4 2011 Prllt Form'�.
APPLICATION FOR SPECIAL
DESIGNATED LICENSE
RETAIL LICENSE HOLDERS
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.Icc.ne.gov/
BEFORE:SUBMITTING APPLICATION TO THE LIQUOR CONTROL COMMISSION .
Include approval from the City, Village or County Clerk where the event is to be held
A license fee $40 (payable to Nebraska Liquor Control Commission) for each day/event to be
licensed (i.e. if you have two separate areas at one event they both need to be licensed) (unless
licensed as a K Caterer no fees required)
0 Application MUST be received at the Liquor Control Commission Office no later than 10 working
days prior to event (excluding weekends, Federal and State observed holidays)
COMPLETE ALL QUESTIONS •
1. Type of alcohol to be served and/or consumed
1 Beer 'Wine 3.4 Distilled Spirits
2. Liquor license number and class (i.e. C-55441) L( 7 o 7
3. Licensee name (last, first, middle), Corporate name, Limited Liability Company (LLC)
NAME: /. ./(..72,)'4 . .1'e A' 41, ("24" dc
ADDRESS: Alamo • si I 71 �� s
CITY . a a , 'e7e ;raJ d ..., ZIP gl e
4. Location where event will be held;name, address, city, county, zip code
ADDRESS: /��,.y ���/ .o-`' _ ,::>/ •
CITY � // ? • ZIP 6-2--jog
COUNTY / %
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REV 6/09 Page 1
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Signature of Manager Applicant Sign ture of Spouse
•
ACKNOWLEDGEMENT
Stare of Nebraska /�
County of . )LLAA M,t/l The foregoing instrunle t was a •n'a ledged before me this
1:05- 611 by ,
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ate n i 8. •' 41 w cri
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Affix Seal
:;Fy P lit sip attire [ .IMET
My Comm.Exp.perch 23,2013
In compliance with the ADA,this application is available in other formats for persons with disabilities.
A ten day advance period is required in writing to produce the alternate format.
Form 103
Rev 1/2011
Pace 5 of$
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Spouses Last Name; First Name: MI:
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a. Is this location within the city/village limits? OYES ONO
b. Is this location within the 150' of church, school,hospital or home
aged/indigent or for veterans their wives? O YES ''NO
c. Is this location within 300' of any university or college campus? 0YESONO
Must be consecutive days
5. ; Date(s)and Time(s)of event(no more then six(6)consecutive da s on one application)
Date azi B r Date Date Date Date Date
Hours From- 4 Hours From Hours From Hours From Hours From Hours From
tiiif% T TQR`ti To To To To To
a. Alternate date:
b. Alternate location: "
(Alternate date or location must be approved by local)
6. Indicate type of activity to be carried on during event
IM DanceJ Reception Fund Raiser Beer Gardenfl Sampling/TastingO Other
7. Description of area to be licensed
O Inside building, dimensions of area to be covered.IN FEET x
Name of building 5 e e r-fr ,.;fy 1�,/ t'/� .✓ti- (not square feet or acres)
Outdoor area dimensions of area to be covered IN FEET P," x
(not square feet or acres)
If outdoor area, how will premises be enclosed
fl fence,type of fenceig snow fenceD chain linkO cattle panels0 other
fl tent _ J
E other,explain f�,),?r, r ,2 `-r-,A<<F f`�� :z)s1 � .r' 4 'ip,!c iiF�`;g
*If both inside and outdoor area to be licensed include simple sketch'7 �. lr ////
8. How many attendees do you expect at event? i,C-/e:' 0. ,4/ l�` •(11
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9. If over 150, indicate the steps that will be taken to prevent underage persons from obtaining alcohol
beverages. j C Vrt;f - .1, . c.712 T t e.- e/.1 f ';"-7; 6'4 17)ci :
10. Will premises to be covered by license comply with all Nebraska sanitation laws?
EYES ONO
a. Are there separate toilets for both men and women? ® YESD1 NO
11. Where will you be purchasing your alcoholO wholesaler@ retailer: both
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12. Will there be any games of chance operatingduring the event? .; YESO NO ,--ft I 1 r-'-,
If so,describe activity 7-74. Er < f';-) r•- i° `"f�,7,=} ,�{6;�,. s `c)fir ; t:
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.
REV 6/09 Page 2
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Spouses Last Name; First Name: MI:
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w many attendees do you expect at event? i,C-/e:' 0. ,4/ l�` •(11
/e: M/C rC) k f-
9. If over 150, indicate the steps that will be taken to prevent underage persons from obtaining alcohol
beverages. j C Vrt;f - .1, . c.712 T t e.- e/.1 f ';"-7; 6'4 17)ci :
10. Will premises to be covered by license comply with all Nebraska sanitation laws?
EYES ONO
a. Are there separate toilets for both men and women? ® YESD1 NO
11. Where will you be purchasing your alcoholO wholesaler@ retailer: both
6, -,"4-" 0 e-t-'13 !.`- 1 j r-t 'i,-;j-{(:-
12. Will there be any games of chance operatingduring the event? .; YESO NO ,--ft I 1 r-'-,
If so,describe activity 7-74. Er < f';-) r•- i° `"f�,7,=} ,�{6;�,. s `c)fir ; t:
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.
REV 6/09 Page 2
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Spouses Last Name; First Name: MI:
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Date Or Birth:
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13. Any other information or requests for exemptions: _....-
14. Name and telephone number/cell phone number of immediate supervisor. This person will be at t
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.
7 ,
% i. ( C " Phone: Before 1(3 -,�?/ O7i During -42� `�--J
Print name of Event Supervisor•
C:- --.9 / /Z-7- .- 1-1-7".",..9--/•-----
Signature of Event S e sor
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 `'yli 1 ".. l „ < i /
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Authorized Representative/Appli t ;"� Title Dat i
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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.
REV 6/09 _ . .. - _— _
Page 3
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.
REV 6/09 Page 2
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Date Or Birth:
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Page 3 of 5
City of Omaha, e bras ��° ' ���s
1819 Farnam—Suite LC 1 so
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Omaha, Nebraska 68183-0112 0� _: ,
Buster Brown (402) 444-5550 •
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City Clerk FAX (402) 444-5263 0 '4'D FEa1°'�4
May 5, 2011
Nebraska Liquor Control Commission
301 Centennial Mall, South
P.O. Box 95046
Lincoln,Nebraska 68509-5046
Attn: Licensing Division
Attached is a copy of the Special Designated License application approved by the City Clerk of
the City of Omaha for Cory, Inc., dba "Welcome Inn Tavern", 2332 South 24th Street for a beer
garden, dance and fundraiser on June 4, 2011 from 12:00 noon to 2:00 a.m. with music until
12:00 midnight.
APPLICATION APPROVED CONTIGENT UPON THE OMAHA CITY COUNCIL
APPROVING THE APPLICATION ON MAY 17, 2011 FOR MUSIC UNTIL 12:00
MIDNIGHT AND 2:00 A.M. OUTDOOR CLOSING
Since ly yours,
uster r
City Clerk
BJB:clj
Enclosure
ecords. 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 `'yli 1 ".. l „ < i /
�,(Y-i?__-•— (�-2 , fryo//' t/ ` "r ",i F r �G)l//;
Authorized Representative/Appli t ;"� Title Dat i
/ e. �c5. ,��"/ / 1//
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.
REV 6/09 _ . .. - _— _
Page 3
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.
REV 6/09 Page 2
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Form 103
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Page 3 of 5
REQUEST FORA SPECIAL DESIGNATED LIQUOR LICENSE.
DATE: MAY 5, 2011.
APPLICANT REQUESTING THE PERMIT:
CORY, INC., DBA "WELCOME INN TAVERN", 2332 SOUTH 24TH STREET
OMAHA, NE
DATE(S) AND TIME(S) OF THE EVENT(S): SATURDAY
JUNE 4, 2011 FROM 12:00 NOON TO 2:00 A.M.
LOCATION: SAME
APPLICANT'S STATUS: X CURRENT LICENSE HOLDER
NON PROFIT ORGANIZATION (STATEMENT ATTACHED)
ADDITIONAL INFORMATION APPLICATION APPROVED CONTIGENT UPON THE
OMAHA CITY COUNCIL APPROVING THE APPLICATION ON MAY 17, 2011
REQUESTING: MUSIC UNTIL 12:00 MIDNIGHT AND 2:00 A.M.
OUTDOOR CLOSING
APPROVED: X
DENIED:
REASON FOR DENIAL:
APPROVED BY: 05/05/2011
Buster Brown, City Clerk, City of Omaha Date
4-8099 * E-MAIL-RKAVANAUGH@LARSONMANAGEMENT.COM
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REQUESTING: MUSIC UNTIL 12:00 MIDNIGHT AND 2:00 A.M.
OUTDOOR CLOSING
APPROVED: X
DENIED:
REASON FOR DENIAL:
APPROVED BY: 05/05/2011
Buster Brown, City Clerk, City of Omaha Date
4-8099 * E-MAIL-RKAVANAUGH@LARSONMANAGEMENT.COM