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RES 2011-0736 - SDL for beer garden at Club Seville July 9 2011 • 7tiTITAIRIMPs,' • • APPLICATION FOR SPECIAL DEgJ[GNATE!11 LICENSE RETAIL LICENSE HOLIIDE!"S 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.lcc.ne.gov/ !:,EFORE SU714VIITTING APPLICATION TO:THE ILIQU CONT OL cCOMMIIISSIION 0 Include approval from the City, Village or County Clerk where the event is to be held El 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) 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 l.. �Type of alcohol to be served anc:/or consumed Lg ypBeer It'Wine '6istilled Spirits 2. Liquor license number and class (Le. C-55441) — "' '""C 3. Licensee name (last, first, middle), Corporate name, Limited Liability Company (LLC) NAME: e i l:i b y e, v� -t \\, , i L L Q ADDRESS: J 1 31) Z.+ CITY 01-0 ' 1 ZIP t&SA,\\ • • 4. • Location where event��'' will be held; name, address, city, county, zip code ADDRESS: 3Lo � D 2. CITY • Cd' '4-- ZIP t.t COUNTY —I) Oc C? • REV 6/09 4 � tt,-M , att .�.., u.. -m .. ,y.,. ,. ..,r_�. w.ua.u..a.. , ..., ,, _ Page 1 a. Is this location within the city/village limits? YES O NO b. Is this location within the 150' of church, school, hospital or home aged/indigent or for veterans their wives? YES 1N` 0/ c. Is this location within 300' of any university or college campus? ©_i YES — 0 Must be consecutive days • 5. Date(s) and Time(s) of event(no more then six(6) consecutive days on one application) Date -7/9 Date Date Date Date Date • Hours From Hours From Hours From Hours From Hours From Hours From • V.4p1 To 41 To To To To To a. Alternate date: b. Alternate location: (Alternate date or location must be approved by local) 6. Inicate type of activity to be carried on}da�ring event Dancefl ReceptionE Fund Raiser EiklBeer Garden 0 Sampling/Tastingfl Other 7.. Description of area to be licensed El Inside building, dimen,siops of area to be covered IN FEET x Name of building C.kut _ .S ki H I k-e_. • (not square feet or acres) s. 7S• Outdoor area dimensions of area to be covered. IN FEET I x (not square feet or acres) If• tdoor area, how will premises be��en��l sed .` fence, type of fence snow fenceNchain linkE cattle panels0 other tent El other, explain rfo S n` ELF. i 1 \ *If both inside and outdoor area to be licensed include simple sketch 8. How many attendees do you-expect at event? • 9. If over 150, indicate the steps that will be taken to prevent underage persons from obtaining alcohol beverages. D 0 4V5a S e.-C-A)e% CA—CAV)--ifV\---t)"AE:•_N6 10. Wil remises to be covered by license comply with all Nebraska sanitation laws? ES ONO a. Are there separate toilets for both men and women? II ESE] NO 11. Where will you be purchasing your alcohol olesalerD retailerE3 both 12. Will there be any games of chance operating during the event? El YESD‘) 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 • � g 1,,, 3. 4 A ,.„, 44....... si 4,1 "i ve> At + M; t' t fi�16,� F S } .1 Itti 5 F 4 j 1 J ' . ram �'.- • • • �,o. 1.3. Any other information or requests for exemptions: 14. Name and telephone number/ce➢8 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. 11 r e t l� \. G 1 SO Phone: Befor e —1�U 3 Durin Z ✓ � Print name Event Supervisor . ‘.7.,-----------------" 2 Signatu• f Event Supervisor L 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 w..,„---(i j ___.- F here .� _ --- _ V _ ._ � --- 5Aut ed Representative/Applicant itle ate //^ FF 1 l vV jayLyik,_ 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 •\ • • 8 01 ` BCD O p . g Crri II. E S '5; cn LS-C33, " r:w rrl w. c:. t:, c) c alb_ eu. , c) 5 Cm... I—' 4' CD ter" o 4 § ,,- ,4.. . • ,„ co 0 SI) CD 'cl:7 to al ‘11t.i)-Si"', CD c. 0, ci: 1