RES 2012-0762 - SDL for beer garden at Old Mattress Factory Bar & Grill July 6-7 2012 APPLICATION FOR SPECIAL
DESIGNATED LICENSE
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/
RETAIL LICENSE HOLDERS.`
NON PROFIT APPLICANTS C]Non Profit Status(check one that best applies)
MunicipalEroliticaluFine Arts Fraternal Religious❑Charitablef 'Public Service_
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Beer IZI Wine #:Distilled Spirits Z
2. Liquor license number and class(i.e.C-55441) C-1 nut
(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: Q fir F 1✓L C
ADDRESS: So N 13
CITY ti i, ZIP (c 11 Q Z
4. Location where event will be held; name,address,city,county,zip code
BUILDING NAME Q( 0 (hNt4r1-SS F PAR c1 6f,(t
�L CITY Ci'r�c-1--c
ADDRESS: ��( � 13
GI I _
ZIP U O l0Z.— COUNTY and COUNTY#
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a. Is this location within the city/village limits? YESnNO
b. Is this location within the 150' of church,school, hospital or home
for aged/indigent or for veterans their wives? YESEC17
c. Is this location within 300' of any university or college campus? YESDIO_
FORM 108
REV 10/11
Page 2 of 5
Title Date
/r1/94C /i Z4C/
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
5. Date(s)and Time(s)of event(no more than six(6)consecutive days on one application)
Date %r're Date —]f1 Date Date Date Date
Hours Hours J Hours Hours Hours Hours
From / I•.c$ From `u.(A. From From From From
To rGv To To To To To
a. Alternate date:
b. Alternate location:
(Alternate date or location must be specified in local approval)
6. Indicate type of activAy to be carried on during event:
Dance OReception LI Fund Raiser[[Beer Garden DSampling/TastinglOther
7. Description of area to be licensed
Inside building,dimensions of area to be covered IN FEET x
Outdoor area dimensions of area to be covered IN FEET 2.0 x 20.
(not square feet or acres)
INCLUDE SKETCH IF OUTDOOR AREA
If outdoor area, how will premises be enclosed?
;i Fence type offence; snow fence❑chain link cattle panel❑other
Tent
Other explain
8. How many attendees do you expect at event? ,90
9. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from
obtaining alcohol beverages. (Attach separa e sheet if needed)
Scp"ora /C 4 a/ci ?ot•CA r Q'� l O.J�1Y;J,,c� I�►w✓��a✓
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10. Will premises to be covered by license comply with all Nebraska sanitatio laws? YES NOT]
a. Are there separate toilets for both men and women?YES ONO
11. Where will you be purchasing your alcohol? Wholesaler ZRetailer El Both❑BYO D
12. Will there be any games of chance operating during the event? YES❑NOE
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: . _
7Y) s/ � A), 1 G' o 7>h4q. /2mi h,; L/
y
FORM 108
REV 10/11
Page 3 of 5
l 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
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e steps that will be taken to prevent underage persons from
obtaining alcohol beverages. (Attach separa e sheet if needed)
Scp"ora /C 4 a/ci ?ot•CA r Q'� l O.J�1Y;J,,c� I�►w✓��a✓
I /
10. Will premises to be covered by license comply with all Nebraska sanitatio laws? YES NOT]
a. Are there separate toilets for both men and women?YES ONO
11. Where will you be purchasing your alcohol? Wholesaler ZRetailer El Both❑BYO D
12. Will there be any games of chance operating during the event? YES❑NOE
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: . _
7Y) s/ � A), 1 G' o 7>h4q. /2mi h,; L/
y
FORM 108
REV 10/11
Page 3 of 5
l 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
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.
Print name of Event Supervisor Paer Yt'a�'
Signature of Event Supervisor
Phone of Event Supervisor: Before %Z.- f J - 1'•�'z During 4(oZ - G.ri- FrSL
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 /i,Z'/Y e12. 5/2Aa.
Authorized Representative/Applicant Title Date
"WCf E�.t 'lt//
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 4of5
REV 10/11
Page 4 of 5
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