RES 2011-1038 - SDL for beer garden at Flixx September 16-17 2011 s +
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 PROFI PPLICANTS Non Profit Status(check one that best apph)
Municipal LPolitical Fine Arts Fraternal . Religious 'Charitable Public Service
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Beer Wine Distilled Spirits
2. Liquor license number and class (i.e. C-55441) C. S
(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: IL d Z ` A- ` (�-
ADDRESS: I 0 �( 0 4-l~ S �..
CITY CD CAA 14 A ZIP 5 (0g
4. Location where event will be name, address, city, county,zip code.
BUILDING NAME ,/ __ X
ADDRESS: ! 0 kcl S .. � CITY O VIA t�
ZIP t8 1p�t 05? COUNTY and COUNTY# k
a. Is this location within the city/village limits? YES 10
b. Is this location within the 150' of church, school, hospital or home —
for aged/indigent or for veterans their wives? YES NO
c. Is this location within 300' of any university or college campus? YES---'/•10 X
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:5. Date(s) and•Time(s) of event (no more than six (6) can ecutive:days on one application).
Date 'c 67 Date •?• e7 Date Date
Date Date
Hours �
Hours Hours Hours Hours Hours
From ,V\ From N co i\ From From From From
To VIT\i c\, Li- To N\ c\.?\,r\1,t To To To To
a. Alternate date:
b. Alternate location:
(Alternate date or lloc stiou 'must be specified in local approval)
6. Indicate type of activity tosbe carried on during event:
Dance LkeceptionE Fund Raiser Y, Beer Garden E[Sampling/Tasting D Other
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_2.. x S' C)
(not square feet or acres)
INCLUDE SIKETCH IF ttUTDSrO;' AREA
If outdoor area, how will premises be enclosed?
Fence(hype of fence; snow fence in chain link H cattle panel[]other t 41-unz> is r.:ILL; t`1
Tent
ct;ther[ I explain j1/7-t:J i C> ki,j / t.-vt /
/p9 /
8. How many attendees do you expect at event? CC: c
9. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from
obtaining alcohol beverages. (Attach separate sheet.i,'needed) - p-e
,
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t,..
10. Will premises to be covered by license comply with all Nebraska tation laws? YES X NO
a. Are there separate toilets for both men and women? YES I O
11. Where will you be purchasing your alcohol? Wholesaler ITRetailer I I Both BYO
12. Will there be any games of chance operating during the event? YESIJIOJ(
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:
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14. Name and tcpephone number/call phone number of immediate superrvisor, 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 A '(\A O t
Signature of Event Supervisor ."y _
r r/
Phone of Event Supervisor: Before 70,d-a - 7 73(-- During vA
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
prized Representative/Applicant Title Date
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.
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