RES 2011-0651 - SDL for beer garden at Berretts Barleycorn June 17-18 2011 r
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MAY-1E'-2011 15:01 From:CITY CLERK/COUNCIL 4024445263 To:94025582852 P.3/5
APPLICATION FOR SPECIAL ..
DESIGNATED LICENSE
RETAIL LICENSE HOLDERS
NEBRASKA LIQUOR C_ON'1 ROL COMMISSION
30t CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NH 68509-S046
PHONE (402)471.2571
FAX (402)471-Vila . .
WOheite Www ICc ne go,/ ...
:BOORS SURII:ITTING,APPLXCATION TO TITS 1.IQ1IOR CONTROL.COMMISSION
❑ Include approval from the City,Village or County Clerk where the event is to be held
❑ A license fee $40(payabl,e 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 IC Caterer no fees required)
• ❑ • 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)
CQMP!ETE ALL QUESTJ:ONS. - .
1, of alcohol to be served and/or consumed
ier C ine Distilled Spirits
2. Liquor license number and class (i.e. C-55441) - /1 37
3, Licensee name(last, first,middle), Corporate name, Limited Liability Company(LLC)
NAME: L'LL11 Aram, 4. r .1,rj/44,,.--5-/Y5�,,-7 2.
ADDRESS: ___y_QA ,,,,,:,,„,,,,,_,A, ,,,,/-- •
c )
CITY 1 „,-.4., ...... ZIP U°g` 4
4. Location where event will be held; name, address, city, county, zip code
• A p-sr: i r
taADUL
,/,,,y /pie, //. eAf.,,,,,,A,5 .s_S--/- -
19CI.TY _.�o' /�,ri-4 _ ZIP e --
COUNTY . .4,;„,././u-5 1....... . ..........i•••••••••
The foregoing instrument was acknowledged before me this
(/�. 'c, ((,. Zo t ( by / p �Cji/AYDc.,
name of pefson acknowledged
07.'2° Affix Seal
`� GENERAL NOTARY-State of Nebraska
Notary Public signature MATT SIMPSON
My Comm;Exp.Nov.9,2014
In compliance with the ADA,this spousal affidavit of non participation is available in other formats for persons with disabilities.
A ten day advance period is requested in writing to produce the alternate format.
FORM 35-4178
Revised 1/2008
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Form 3c Page 2
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MAY-10-2011 15:01 From:CITY CLERK/COUNCIL 4024445263 To:94025582852 P.4/5•
is this location within the ci /villa a limits? L`t Y.ES 0 NO
a, h' g
b, is this location within the 150' of church, school, hospital or home
aged/indigent or for veterans their wives? ❑ YES C?_1
c. Is this location within 300' of any university or college campus? 11 YES I "NO
Must be consecutive days
5. Date(s) and Time(slof even rio more then six (6)consecutive days op one application) - - .
Date i�., /,7 ' Date i.. i �%�; Date Date Date Date
Hours ro f
m Hours Prom Hours From Hours Prom Hours From }lours From
ld�' „T A�"j,�.• �'`�,,,, Tn)Rtr To To To... To
a. Alternate date: N/4" ,
b. Alternate location: Ait 4' —
(Alternate date or loca ion must be approved by local)
6. Indicate type of activity to be carried on ur-ing event
0 Nance 0 Reception ❑ Fund Raiser . Beer. Garden 0 Sampling/Ta_sting 0 Other ,
7. Description of area to be licensed
O Inside building,dimensions of area to be covered IN FEET .. x
Name of building (not square feet or acres)
.)s •
. Outdoor area dimensions of area to be covered )IN FEET 45d ,x ` i)
(not square feet or acres)
ifputdoor area, how will premises be-e losed
PI fence, type of fence 0 snow.fence chain link I) cattle panels 0 other ,
[ tent Ai ()Cl other, explain . . &4sic � ;: ,�
*If both inside and outdoor area to be licensed include simple sketch , Y J z 4r'%3 f'_
' - (C' '1\
8. How many attendees do you expect at event? 0
9. If over 150, indicate the steps that will be taken to preven,,...,,,7 egi,,t underage persons from obtaining alcohol
beverages. `"�'
,,,c4,,,z.-,:,,,..,
10. W' .. premises to be covered by license comply with all Nebraska sanitation laws?
!3 YES ONO �
a. Are there separate toilets for both men and women? 0 YES11NO
11. Where will you be purchasing your alcohol - wholesaler. 0 retailer 0 both
1.2. Will there be any games of chance operating during the event? 0 YES lli'NO
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
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Form 3c Page 2
1
MAY-10-2011 15:01 From:CITY CLERK/COUNCIL 4024445263 To:94025582852 P.5/5
13, Any other information or requests for exemptions;
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.
/ r ,i gArAL.OITA1K:41-7Phone: Before 7 Dutiug
Print name of vent Superv. r
Signet c f Event Supervise
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 co oration for profit or not for profit and that the event will be supervised by persons
directly respo•si e to the h er of this Special Designated License.
fir _ /ice
sign r �G7f
here .... .. � � �--- , ..
u orized Representative/ plicant Title Date
—
Print Name
stockholder individual must be listed on the application as an officer or ,tockhatder 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 it'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.
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
nermil annli can on.
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