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RES 2011-0606 - SDL for beer garden and live music at Starsky's June 17-22 2011 Print 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 0 Include approval from the City,Village or County Clerk where the event is to be held 0 A license fee $40(payable to Nebraska Liquor Control Commission) for each day/event to be licensed(i.e. if you have two separate areas at one event they both need to be licensed)(unless licensed as a K Caterer no fees required) 0 Application MUST be received at the Liquor Control Commission Office no later than 10 working days prior to event(excluding weekends, Federal and State observed holidays) COMPLETE ALL QUESTIONS /7✓12-// 1. Type of alcohol to be served and/or consumed til,Beer Wine tYit Distilled Spirits 2. Liquor license number and class(i.e. C-55441) C° K 75'$'E 1 3. Licensee name(last, first, middle),Corporate name, Limited Liability Company(LLC) NAME: t orICTLAi1tr h IvtG.-rytTilityft ( t,,nikpal') C 1 S++;{sk-ki CITY �Y Ck ZIP cam-/ 4. Location where event will be held;name, address,city,county,zip code ADDRESS: '4 C 2—Z) 3. I J1 11 CITY Dort(Ion ZIP (% 101 • COUNTY 7)0 LI REV 6/09 Page 1 arned, Catnival•ride operator must carry at least equal GL limits verified with a ccrtVicate, Please forward cert. from Co on the Carnival rides. Thank.You, • Advance Premium 750,00 . Policy Fee 90.00 • Surplus Lines Tax -25,20 Totals -8865,20 • • The premium shown herein is a minimum & deposit premium. in the event that coverage is to effect forthe full term the premium is fully earned& no return premium will be allowed at the time of audit, in the event that coverage is not in effect for the lull term,The earned pretniurn will be computed in accordance with the terms .condition:,of the policy but In no event will it be less than the minimum earned premium of 25%plus lees. This Company binds,ne kind(s)of insurance stipulated heroin. This insurance is subject to the terms, conditions and limitations of the policy(s) in current use by the Company, The birder may be canceled by the insured bysurrendor of this binder or by written notice to the Company stating when cancellation will be effective--subject to minimum earned premium. The binder may be canceled by the Company by notice to the insured in accordance with the policy conditions., This binder is canceled when replaced by a policy. Data of Issuance:April 28,2011 Sighed: 0 C Daniels . •4•61b, •.5rirei,,t.°4.,....f At,•'i '''''4•7: ...AP:.„ ., t,... • . . Spouses Last Name; First Name: MI: 10 I A Social Security Number:, • Drivers License Number& State: — . r•a:n:..4... .riac,..;Of.i.. .i.w.,.. . . Date Or Birth: pr•-..1.61=T......C. 911... .." CCLIM.1......' ..,... : 7...4•7 ./ '' t , ?'',T fk'llAWil4,i1.1X:': , ,,. . .,,,,,, ..4:.s. . r, 7 .: i.4,01,?..T•gg.,Ip.,....ul ..,..w.4*,..• • .,...k,x4:-,4.:It• .- --Trs. •,..-..i1.-,r0A7•71:t.,- 44-,32_,11..., ,,. ,-;,.. .,,A.,,. ,.. ....v..,4_,..i._,.‘;:•.„....,-.s.:. fyitr,d,,,... ,--,.,, ", ,..0.,,.., 7.4,,, - •• ' ' t"`,.4.1-..i., -P'-'1•• ...,,a,k1,,•,,,,- "d,,,fiteTWA,Mik-A,,,,.." "Z r:.;..', ,t.r..d$.... .1., ,,,,..7,..?4,... ,,, ,.. ,..,,,,z.,,,,.. ... .,..„.,,,,, .',..,,,,c,,,j.,,,,,I, t, ,44..., ,, „...4 .,. .e., . __.,,t.4...,.:„..,nrl_,a,„ ,..,„„.,v,. .444,, ,•••4:‘,.....7-,,..A•5,:,:;:j,;,4,,,,,tta=1:.....z.,. ;"....A.,0.,•,.•:f.....-,.... . 0,. ,. - ) ,i,„,,,,,,,c'V,.o.,,;•za ill.•„_.,4§3.,.‘i.,..:71..., :. "4., .,4..1.....7,..'.71........r.,...1,..1.yr.60.......k.f.i.: 1. ' .r.,74:T.,,../....*.3.X•ft. e. - :4. •4..t4.1c,.q,.............4 i,.... .4.,,i iet,r. ,...,,,,,,, ,4,,,,riltlerf 1",, •'::..,,,r,6.'epy.L.,..4 .4,p4c,.. . ,4 , ,;,--4...,,,A,:Sg4.,6*,,,,, ..ets ',.;,.4e.,,,,tt, .". 1,1,C._,Atr.i... ....,5"641 ,,thatt a,...... ,..'". •' ..... C'S'4,4,e''l)trn Ir'.;c--,Nit 4 E,..4\-17,1'1:N. t3.'5";',44"5•Moe,,,11-.:.•:4-• . ''' •::`244-',.LAt-*Zt''''I'''''' ' *-- • . . • r env & STATE . I YEAR YEAR CITY &STATE YEAR YEAR F FROM TO FROM TO ge .3/4IN As-- 4 tR -goi 0 Piwoh+ Lk ocl ow 1 1-_ Li4c..3k lc 200 o".17 i 002s- Ai mslievc.,Plazk Org462,_ . • ,33 5- c Ar 2 0E8 2 tl,ut Om 0 am D ...6t1 kj4k.oi Ce1noteab-in LinGivh, %a,tAown.51. 0 ThellIA, AAT ..._ r2— goo3 , Lilth it._ aon a.610, 1;04 0 vdit• 5+. Li.D9C•01 r2 l&C 1 1171/ /1/41. LIticAv vv Form 103 R,,,inai 1 Page 3 of 5 { 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? ©YES ONO c. Is this location within 300' of any university or college campus? ❑YESANO Must be consecutive days 5. Date(s)and Time(s) of event(no more then six(6)consecutive days on one application) Date _. '1 Date L_,11.) Date EG%-11 Date � Date( �J Date jc: Hours From Hours From Hours From Hours From Hours From Hours From 0-Ftk To t an/1 lvM To 1.41v► e if1 To IWI,1 sem_ To\.NriA To i'Vyk Spt4k To I W1, a. Alternate date: j b. Alternate location: I\C, e. (Alternate date or location must be approved by local) 6. Indicate type of activity to be carried on during event Dance© Reception!: Fund Raiser� 0 BeerGarden Sampling/Tasting0 Other 1...iUe,, kto iL, 7. Description of area to be licensed ❑Inside building,dimensions of area to be covered IN FEET C x / (ru Name of building -,211F-gl. S (not square feet or acres) Outdoor area dimensions of area to be covered IN FEET i L0 x 4 c,J (not square feet or acres) If outdoor area,how will premises be enclosed ELfence,type of fenceD snow fenceD chain linkD cattle panels other tt l `c Y i V tent CI other,explain 14 \ k_9 S /•C (. s,) ) 6'v, / 4 /41 *If both inside and outdoor area to be licensed include simple sketch 8. How many attendees do you expect at event? I &> 9. If over 150, indicate the steps that will be taken to prevent underage persons from obtaining alcohol beverages. &c E, i-Vancie- Vvtt\ c\ a prov lac k 5ibay-Os No itilAe oo pry .. 1 v.I►U io 1 n c c4a.bli sh rvlevi+- (1-00' '? Y&• I0. Will premises to be covered by license comply with all Nebraska sanitation laws? %YES © NO a. Are there separate toilets for both men and women? J'YESD NO 11. Where will you be purchasing your alcohol wholesalerD retailer0 both 12. Will there be any games of chance operating during the event? © YESJNO 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. REV 6/09 Page 2 r may be canceled by the Company by notice to the insured in accordance with the policy conditions., This binder is canceled when replaced by a policy. Data of Issuance:April 28,2011 Sighed: 0 C Daniels . •4•61b, •.5rirei,,t.°4.,....f At,•'i '''''4•7: ...AP:.„ ., t,... • . . Spouses Last Name; First Name: MI: 10 I A Social Security Number:, • Drivers License Number& State: — . r•a:n:..4... .riac,..;Of.i.. .i.w.,.. . . Date Or Birth: pr•-..1.61=T......C. 911... .." CCLIM.1......' ..,... : 7...4•7 ./ '' t , ?'',T fk'llAWil4,i1.1X:': , ,,. . .,,,,,, ..4:.s. . r, 7 .: i.4,01,?..T•gg.,Ip.,....ul ..,..w.4*,..• • .,...k,x4:-,4.:It• .- --Trs. •,..-..i1.-,r0A7•71:t.,- 44-,32_,11..., ,,. ,-;,.. .,,A.,,. ,.. ....v..,4_,..i._,.‘;:•.„....,-.s.:. fyitr,d,,,... ,--,.,, ", ,..0.,,.., 7.4,,, - •• ' ' t"`,.4.1-..i., -P'-'1•• ...,,a,k1,,•,,,,- "d,,,fiteTWA,Mik-A,,,,.." "Z r:.;..', ,t.r..d$.... .1., ,,,,..7,..?4,... ,,, ,.. ,..,,,,z.,,,,.. ... .,..„.,,,,, .',..,,,,c,,,j.,,,,,I, t, ,44..., ,, „...4 .,. .e., . __.,,t.4...,.:„..,nrl_,a,„ ,..,„„.,v,. .444,, ,•••4:‘,.....7-,,..A•5,:,:;:j,;,4,,,,,tta=1:.....z.,. ;"....A.,0.,•,.•:f.....-,.... . 0,. ,. - ) ,i,„,,,,,,,c'V,.o.,,;•za ill.•„_.,4§3.,.‘i.,..:71..., :. "4., .,4..1.....7,..'.71........r.,...1,..1.yr.60.......k.f.i.: 1. ' .r.,74:T.,,../....*.3.X•ft. e. - :4. •4..t4.1c,.q,.............4 i,.... .4.,,i iet,r. ,...,,,,,,, ,4,,,,riltlerf 1",, •'::..,,,r,6.'epy.L.,..4 .4,p4c,.. . ,4 , ,;,--4...,,,A,:Sg4.,6*,,,,, ..ets ',.;,.4e.,,,,tt, .". 1,1,C._,Atr.i... ....,5"641 ,,thatt a,...... ,..'". •' ..... C'S'4,4,e''l)trn Ir'.;c--,Nit 4 E,..4\-17,1'1:N. t3.'5";',44"5•Moe,,,11-.:.•:4-• . ''' •::`244-',.LAt-*Zt''''I'''''' ' *-- • . . • r env & STATE . I YEAR YEAR CITY &STATE YEAR YEAR F FROM TO FROM TO ge .3/4IN As-- 4 tR -goi 0 Piwoh+ Lk ocl ow 1 1-_ Li4c..3k lc 200 o".17 i 002s- Ai mslievc.,Plazk Org462,_ . • ,33 5- c Ar 2 0E8 2 tl,ut Om 0 am D ...6t1 kj4k.oi Ce1noteab-in LinGivh, %a,tAown.51. 0 ThellIA, AAT ..._ r2— goo3 , Lilth it._ aon a.610, 1;04 0 vdit• 5+. Li.D9C•01 r2 l&C 1 1171/ /1/41. LIticAv vv Form 103 R,,,inai 1 Page 3 of 5 i I �^ 1 f L A O O O C p, vpi CD CD g' 0 --- 1 C �, 0 ,_,. . .. O As„ (D IQ Q. tri O ,.• � "! .—. O d O p O d ►-` (7 �• _ `�S C vpi ' ONO N • N '-' 0 v' c ..• 000 000 (D O • : ,c-r e nH CQG+O 64' 'O' O c-, v, 0 k \ O O' 0. n N O o� O w ° n `eD g '� I..) IQO• Pt', A> v � E• cp � rr U. 05/05/2011 Buster Brown, City Clerk, City of Omaha Date 4-8099 * E-MAIL-RKAVANAUGH@LARSONMANAGEMENT.COM 9 13. Any other information or requests for exemptions: , �(��;. � ������' ar ea talk c) ' tic! � ���c' l Lr'}'l��' 14. Name and telephone number/cell phone number of immediate supervisor. This person will be at t SiL by the location of the event when it occurs, able to answer any questions from Commission and/or law .4g ben/ enforcement before and during the event, and who will be responsible for ensuring that any applicable laws, c- Y de ordinances, rules and regulations are adhered to. 1 I r I S f i 1-b b r v I c k Phone: Before 2402-1 g" 519 3 During 62--o g-6j 7`1 Print name of Event Supervisor VO:e jeK.IM V4\--) Signa ure of Event Supervisor 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 r.<"/�,�,� � C �s%� � C Y1�dljf ) fit` -7-z Authorized Representative/Applicant Title Date Jr � i l �'Ct 1 vid) 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 REV 6/09 Page 2 r may be canceled by the Company by notice to the insured in accordance with the policy conditions., This binder is canceled when replaced by a policy. Data of Issuance:April 28,2011 Sighed: 0 C Daniels . •4•61b, •.5rirei,,t.°4.,....f At,•'i '''''4•7: ...AP:.„ ., t,... • . . Spouses Last Name; First Name: MI: 10 I A Social Security Number:, • Drivers License Number& State: — . r•a:n:..4... .riac,..;Of.i.. .i.w.,.. . . Date Or Birth: pr•-..1.61=T......C. 911... .." CCLIM.1......' ..,... : 7...4•7 ./ '' t , ?'',T fk'llAWil4,i1.1X:': , ,,. . .,,,,,, ..4:.s. . r, 7 .: i.4,01,?..T•gg.,Ip.,....ul ..,..w.4*,..• • .,...k,x4:-,4.:It• .- --Trs. •,..-..i1.-,r0A7•71:t.,- 44-,32_,11..., ,,. ,-;,.. .,,A.,,. ,.. ....v..,4_,..i._,.‘;:•.„....,-.s.:. fyitr,d,,,... ,--,.,, ", ,..0.,,.., 7.4,,, - •• ' ' t"`,.4.1-..i., -P'-'1•• ...,,a,k1,,•,,,,- "d,,,fiteTWA,Mik-A,,,,.." "Z r:.;..', ,t.r..d$.... .1., ,,,,..7,..?4,... ,,, ,.. ,..,,,,z.,,,,.. ... .,..„.,,,,, .',..,,,,c,,,j.,,,,,I, t, ,44..., ,, „...4 .,. .e., . __.,,t.4...,.:„..,nrl_,a,„ ,..,„„.,v,. .444,, ,•••4:‘,.....7-,,..A•5,:,:;:j,;,4,,,,,tta=1:.....z.,. ;"....A.,0.,•,.•:f.....-,.... . 0,. ,. - ) ,i,„,,,,,,,c'V,.o.,,;•za ill.•„_.,4§3.,.‘i.,..:71..., :. "4., .,4..1.....7,..'.71........r.,...1,..1.yr.60.......k.f.i.: 1. ' .r.,74:T.,,../....*.3.X•ft. e. - :4. •4..t4.1c,.q,.............4 i,.... .4.,,i iet,r. ,...,,,,,,, ,4,,,,riltlerf 1",, •'::..,,,r,6.'epy.L.,..4 .4,p4c,.. . ,4 , ,;,--4...,,,A,:Sg4.,6*,,,,, ..ets ',.;,.4e.,,,,tt, .". 1,1,C._,Atr.i... ....,5"641 ,,thatt a,...... ,..'". •' ..... C'S'4,4,e''l)trn Ir'.;c--,Nit 4 E,..4\-17,1'1:N. t3.'5";',44"5•Moe,,,11-.:.•:4-• . ''' •::`244-',.LAt-*Zt''''I'''''' ' *-- • . . • r env & STATE . I YEAR YEAR CITY &STATE YEAR YEAR F FROM TO FROM TO ge .3/4IN As-- 4 tR -goi 0 Piwoh+ Lk ocl ow 1 1-_ Li4c..3k lc 200 o".17 i 002s- Ai mslievc.,Plazk Org462,_ . • ,33 5- c Ar 2 0E8 2 tl,ut Om 0 am D ...6t1 kj4k.oi Ce1noteab-in LinGivh, %a,tAown.51. 0 ThellIA, AAT ..._ r2— goo3 , Lilth it._ aon a.610, 1;04 0 vdit• 5+. Li.D9C•01 r2 l&C 1 1171/ /1/41. LIticAv vv Form 103 R,,,inai 1 Page 3 of 5 0tANHA, N� .City of Omaha, Nebraska Leirdr4fi-%tri ^ 1819 Farnam-Suite LC 1E d1 _ Omaha, Nebraska 68183-0112O x -'': "' Buster Brown (402) 444-5550 .o City Clerk FAX (402) 444-5263 oR�TF� FEBX�t'�4 May 3, 2011 Todorovich Management Company Applications for a Special Designated Dba "Starsky's " License for June 17-20 & 24-29, 2011 4020 South 13th Street requesting music until 1:00 a.m. Omaha, NE 68107 Dear Liquor License Applicant: This letter is notification that a hearing before the Omaha City Council on your application(s) for a Special Designated liquor license has been set for May 17, 2011 . The City Council Meeting begins at 2:00 P.M. in the Legislative Chamber, (LC-4), Omaha/Douglas Civic Center, 1819 Farnam Street, Omaha, Nebraska. City Council Liquor Rule No. 6 states,."Each applicant for any type of license shall be personally present in the Council Chambers, in order that the Council may make inquiries, on the date of public hearing of the application for said license". Failure to be present at this Council Meeting is grounds to recommend denial of your application(s) to the Nebraska Liquor Control Commission. Since, ely yours, Buster Brown City Clerk BJB:clj 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 r.<"/�,�,� � C �s%� � C Y1�dljf ) fit` -7-z Authorized Representative/Applicant Title Date Jr � i l �'Ct 1 vid) 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 REV 6/09 Page 2 r may be canceled by the Company by notice to the insured in accordance with the policy conditions., This binder is canceled when replaced by a policy. Data of Issuance:April 28,2011 Sighed: 0 C Daniels . •4•61b, •.5rirei,,t.°4.,....f At,•'i '''''4•7: ...AP:.„ ., t,... • . . Spouses Last Name; First Name: MI: 10 I A Social Security Number:, • Drivers License Number& State: — . r•a:n:..4... .riac,..;Of.i.. .i.w.,.. . . Date Or Birth: pr•-..1.61=T......C. 911... .." CCLIM.1......' ..,... : 7...4•7 ./ '' t , ?'',T fk'llAWil4,i1.1X:': , ,,. . .,,,,,, ..4:.s. . r, 7 .: i.4,01,?..T•gg.,Ip.,....ul ..,..w.4*,..• • .,...k,x4:-,4.:It• .- --Trs. •,..-..i1.-,r0A7•71:t.,- 44-,32_,11..., ,,. ,-;,.. .,,A.,,. ,.. ....v..,4_,..i._,.‘;:•.„....,-.s.:. fyitr,d,,,... ,--,.,, ", ,..0.,,.., 7.4,,, - •• ' ' t"`,.4.1-..i., -P'-'1•• ...,,a,k1,,•,,,,- "d,,,fiteTWA,Mik-A,,,,.." "Z r:.;..', ,t.r..d$.... .1., ,,,,..7,..?4,... ,,, ,.. ,..,,,,z.,,,,.. ... .,..„.,,,,, .',..,,,,c,,,j.,,,,,I, t, ,44..., ,, „...4 .,. .e., . __.,,t.4...,.:„..,nrl_,a,„ ,..,„„.,v,. .444,, ,•••4:‘,.....7-,,..A•5,:,:;:j,;,4,,,,,tta=1:.....z.,. ;"....A.,0.,•,.•:f.....-,.... . 0,. ,. - ) ,i,„,,,,,,,c'V,.o.,,;•za ill.•„_.,4§3.,.‘i.,..:71..., :. "4., .,4..1.....7,..'.71........r.,...1,..1.yr.60.......k.f.i.: 1. ' .r.,74:T.,,../....*.3.X•ft. e. - :4. •4..t4.1c,.q,.............4 i,.... .4.,,i iet,r. ,...,,,,,,, ,4,,,,riltlerf 1",, •'::..,,,r,6.'epy.L.,..4 .4,p4c,.. . ,4 , ,;,--4...,,,A,:Sg4.,6*,,,,, ..ets ',.;,.4e.,,,,tt, .". 1,1,C._,Atr.i... ....,5"641 ,,thatt a,...... ,..'". •' ..... C'S'4,4,e''l)trn Ir'.;c--,Nit 4 E,..4\-17,1'1:N. t3.'5";',44"5•Moe,,,11-.:.•:4-• . ''' •::`244-',.LAt-*Zt''''I'''''' ' *-- • . . • r env & STATE . I YEAR YEAR CITY &STATE YEAR YEAR F FROM TO FROM TO ge .3/4IN As-- 4 tR -goi 0 Piwoh+ Lk ocl ow 1 1-_ Li4c..3k lc 200 o".17 i 002s- Ai mslievc.,Plazk Org462,_ . • ,33 5- c Ar 2 0E8 2 tl,ut Om 0 am D ...6t1 kj4k.oi Ce1noteab-in LinGivh, %a,tAown.51. 0 ThellIA, AAT ..._ r2— goo3 , Lilth it._ aon a.610, 1;04 0 vdit• 5+. Li.D9C•01 r2 l&C 1 1171/ /1/41. LIticAv vv Form 103 R,,,inai 1 Page 3 of 5 71, ,10,, 444 ... 6,41.. • oft o CD p .k... mi, .-- ,-- cy , p+ \ flt aAli \-! 0PA r y CDF d � o � E• N -, � �! '� 1 " J �• _ `�S C vpi ' ONO N • N '-' 0 v' c ..• 000 000 (D O • : ,c-r e nH CQG+O 64' 'O' O c-, v, 0 k \ O O' 0. n N O o� O w ° n `eD g '� I..) IQO• Pt', A> v � E• cp � rr U. 05/05/2011 Buster Brown, City Clerk, City of Omaha Date 4-8099 * E-MAIL-RKAVANAUGH@LARSONMANAGEMENT.COM