RES 2009-0356 - SDL for beer garden at Roja Mexican Grill and Margarita Bar May 5 2009 s
OF, l
Cityof =I maha . eras 1
OA
1819 Farnam—Suite LC 1 pr E-- iCO
Omaha, Nebraska 68183-0112 o
Buster Brown (402) 444-5550
City Clerk FAX (402) 444-5263 o4)9rtp FE130�t'��
March 31, 2009
Roja, LLC Application for a Special Designated
Dba "Roja Mexican Grill & Margarita Bar" License for May 5, 2009
17010 Wright Plaza #100 (Music to end at 1:00 a.m.)
Omaha, NE 68130
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 April 14,
2009.
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.
Sincerely yours,
4411rIF t�i-41
Buster Brown
City Clerk
BJB:clj
.
Sincerely yours,
Buster Brown
City Clerk
BJB:clj
°buy Publi tare Notary Public signature
Affix Seal Here Affix Seel Here
((1.4.E:0-% ROP,L.:+'D Pi.SELLS it
,'""*"."•,:l MY Co'
Ic';'f,4;it4; t.• "
' :I V,'441
In compliance with the ADA.this manager insert form 3c is avaihtble in other fermate for parses with disabilities.
A ten day advance period is required in writing to produce the alternate format 1
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" Revised srross
Form 3c Page 4
e-Responsible Beverage Service Training
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Form 3c Page 3
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Form 3c Page 2
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--,--.... e.M' f‘ '°V. CORPORATE OFFICER SIGNA
----'-g--k ROSALIND R.SELLS
MY COMMISSION EXJ'JRES
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, ........ May11,2011
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Form 3c III
0900005088
.._ _. _ • ,
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County or-Do..r45►5 The foregoing instrument was acknowledged before me this
5'f-�1 �ck_n�,,� t� c�o0 9 by �ess i co— 111 �T'
da name of person acknowledged
Affix Seal
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N Public signatu LORI MILES
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ignatur ividual involved with application Printed name o.f applying individual
(Spouse o dividual listed above)
State of �5 .0---
County of'�o v,Q1 S The foregoing instrument was acknowledged before me this
5-4- DJ�✓1 L ar1 000 Cf by e �' t l ►T�
da name of person acknowledged
r
Affix Seal
—' ERAL NOTARY•State of Nebraska
otary Public sig attire mm€ MILES •
My Ctxrun.Grp.Oct.10,2010
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 1n008
Cityof [Are Omaharas
1819 Farnam— Suite LC 1prApktim
to,
Omaha, Nebraska 68183-0112 0 v.w
Buster Brown (402) 444-5550 t0
City Clerk FAX (402) 444-5263 OBRvA
March 31, 2009
Roja, LLC Application for a Special Designated
Attn: Nick Hogan License for Roja, LLC, dba "Roja Mexican
3918 North 138th Street Grill & Margarita Bar", 17010 Wright
Omaha, NE 68164 Plz #100 on May 5, 2009 (Music to end
at 1:00 a.m.)
Dear Liquor License Applicant Attorney:
This letter is notification that a hearing before the Omaha City Council on the
application(s) for a Special Designated liquor license has been set for April 14,
2009.
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
the application(s) to the Nebraska Liquor Control Commission.
Sincerely yours,
Buster Brown
City Clerk
BJB:clj
erk
BJB:clj
.
Sincerely yours,
Buster Brown
City Clerk
BJB:clj
°buy Publi tare Notary Public signature
Affix Seal Here Affix Seel Here
((1.4.E:0-% ROP,L.:+'D Pi.SELLS it
,'""*"."•,:l MY Co'
Ic';'f,4;it4; t.• "
' :I V,'441
In compliance with the ADA.this manager insert form 3c is avaihtble in other fermate for parses with disabilities.
A ten day advance period is required in writing to produce the alternate format 1
• •• -, r .Ti'
" Revised srross
Form 3c Page 4
e-Responsible Beverage Service Training
t,
I megmlimmenimmomillimmionom
Form 3c Page 3
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Form 3c Page 2
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Form 3c
0900005087.
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--,--.... e.M' f‘ '°V. CORPORATE OFFICER SIGNA
----'-g--k ROSALIND R.SELLS
MY COMMISSION EXJ'JRES
Tufaf),,..,
Sho,
, ........ May11,2011
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.. •A axed si us ;tun*are : - 'table
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Form 3c III
0900005088
.._ _. _ • ,
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County or-Do..r45►5 The foregoing instrument was acknowledged before me this
5'f-�1 �ck_n�,,� t� c�o0 9 by �ess i co— 111 �T'
da name of person acknowledged
Affix Seal
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N Public signatu LORI MILES
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ignatur ividual involved with application Printed name o.f applying individual
(Spouse o dividual listed above)
State of �5 .0---
County of'�o v,Q1 S The foregoing instrument was acknowledged before me this
5-4- DJ�✓1 L ar1 000 Cf by e �' t l ►T�
da name of person acknowledged
r
Affix Seal
—' ERAL NOTARY•State of Nebraska
otary Public sig attire mm€ MILES •
My Ctxrun.Grp.Oct.10,2010
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 1n008
tJ11I !Of(T1 �•;F1
APPLICATION FOR SPECIAL ttt
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.lcc.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 Include signed statement from the local law enforcement(see question#8) -
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
1. , Tpe of alcohol to be served and/or consumed
Beer 0 Wine laDistilled Spirits
2. Liquor license number and class (i.e. C-55441) • a to Gs 51
3. Licensee name (last, first, middle), Corporate name, Limited Liability Company (LLC)
NAME: g9 A V"�.- I (LWI ei V1 It curd, V V ati"f `vi Z
ADDRESS: I l WC I(L.- 71LIM COUNTY Jl�l lit
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Notary Public signature
Affix Seal Here Affix Seel Here
((1.4.E:0-% ROP,L.:+'D Pi.SELLS it
,'""*"."•,:l MY Co'
Ic';'f,4;it4; t.• "
' :I V,'441
In compliance with the ADA.this manager insert form 3c is avaihtble in other fermate for parses with disabilities.
A ten day advance period is required in writing to produce the alternate format 1
• •• -, r .Ti'
" Revised srross
Form 3c Page 4
e-Responsible Beverage Service Training
t,
I megmlimmenimmomillimmionom
Form 3c Page 3
' :.: s - `r
Form 3c Page 2
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0 ,1', :1 III 1 011 01
Form 3c
0900005087.
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--,--.... e.M' f‘ '°V. CORPORATE OFFICER SIGNA
----'-g--k ROSALIND R.SELLS
MY COMMISSION EXJ'JRES
Tufaf),,..,
Sho,
, ........ May11,2011
-a---.I
.. •A axed si us ;tun*are : - 'table
4, is: A se, •,' 0-„,--, * 1,* -4--;,- 7, 14- 1' ‘r'.•-t- ...,t;-.4 "1r 4 1 * -'4'''' 111
Form 3c III
0900005088
.._ _. _ • ,
�
County or-Do..r45►5 The foregoing instrument was acknowledged before me this
5'f-�1 �ck_n�,,� t� c�o0 9 by �ess i co— 111 �T'
da name of person acknowledged
Affix Seal
���-,e. tt GENERAL NOTARyex tate of Nebraskil
N Public signatu LORI MILES
My carom.Exp.OG.10,2010
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•
klie....I.... ti;i4CF"
ignatur ividual involved with application Printed name o.f applying individual
(Spouse o dividual listed above)
State of �5 .0---
County of'�o v,Q1 S The foregoing instrument was acknowledged before me this
5-4- DJ�✓1 L ar1 000 Cf by e �' t l ►T�
da name of person acknowledged
r
Affix Seal
—' ERAL NOTARY•State of Nebraska
otary Public sig attire mm€ MILES •
My Ctxrun.Grp.Oct.10,2010
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 1n008
�.� ct ,m/-e y -7 //
4. Location where event will be held;name, address, city, county, zip code
ADDRESS: • COUNTY (oil l lit
k.
a. Is this location within the city/vil age limits? M YES D NO
b. Is this location within the 150' of church, school, hospital or home
aged/indigent or for veterans their wives? t1 YESO NO
c. Is this location within 300' of any university or college campus? 0 YESKI NO
5. Date(s) and.Time(s) of event(no more then six (6)consecutive days on one application)
s
DateLy � ��� �_ Date Date Date Dal Date
Hours From Hours From Hours From Hours From Hours From Hours From
iittir To iani To To To To To
a. Alternate date:. n rl...._.. _
b. Alternate location: irYi
(alternate date or location must be approved by local and law enforcement)
6. Indicate type of activity to be carried on during event,
Dance O Reception D Fund Raiser 0 Beer Garden 0 Sampling/Tasting M Other IM51 C,
7. Description of area to be licensed
Inside building, dimensions of area to be covered INFEET x
Name of building (not square feet or acres)
Outdoor area dimension of area to be covered INFEET x QQ
(not square feet or acres)
If outdoor area, how will premises be enclosed
fence, type of fence •
tent
D other, explain / Y U4 .) it c fj l/ ei/o //1/44
*If both inside and outdoor area to be licensed include simple sketch
8. Attach a signed statement from local police chief or county sheriff, whichever is applicable, that local
law enforcement has been informed in advance of this event, and if they are aware of any reason the
event should not occur.
9. Indicate the steps that will be taken top event undera e persons from obtaining alcohol beverages.
d c c-{71 efV ) iU '5 f.zU'id OW ail" eiLe. 2-1 aro( ev -.
10. Will premises to be covered by license comply with 11 Nebraska sanitation laws?
YES O NO
a. Are there separate toilets for both men and women? 1I YES El NO
Form 3c Page 2
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0 ,1', :1 III 1 011 01
Form 3c
0900005087.
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,'' 4,-,s,4 40,-,-,',,, ...:*4! 4,, _it-,,,i,-;,,, oir k 0 i...Or-..24jt i.itif:.6'''.*,_Iiii^ ze 4*.•,-1/2;#1-?","),. t,4Ir $1 4t 1
--,--.... e.M' f‘ '°V. CORPORATE OFFICER SIGNA
----'-g--k ROSALIND R.SELLS
MY COMMISSION EXJ'JRES
Tufaf),,..,
Sho,
, ........ May11,2011
-a---.I
.. •A axed si us ;tun*are : - 'table
4, is: A se, •,' 0-„,--, * 1,* -4--;,- 7, 14- 1' ‘r'.•-t- ...,t;-.4 "1r 4 1 * -'4'''' 111
Form 3c III
0900005088
.._ _. _ • ,
�
County or-Do..r45►5 The foregoing instrument was acknowledged before me this
5'f-�1 �ck_n�,,� t� c�o0 9 by �ess i co— 111 �T'
da name of person acknowledged
Affix Seal
���-,e. tt GENERAL NOTARyex tate of Nebraskil
N Public signatu LORI MILES
My carom.Exp.OG.10,2010
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;' 1;f4. A ,I, f'JY C.d 11 :tl •',., , { '- I.r !iL ul.' �` :tC.q. 'i=T. •1-i r '` •^r 1H:..:'U� f. ld �' .14 td :.�F ^(ir'�!',�•x�^_ ,,p.li,.
•
klie....I.... ti;i4CF"
ignatur ividual involved with application Printed name o.f applying individual
(Spouse o dividual listed above)
State of �5 .0---
County of'�o v,Q1 S The foregoing instrument was acknowledged before me this
5-4- DJ�✓1 L ar1 000 Cf by e �' t l ►T�
da name of person acknowledged
r
Affix Seal
—' ERAL NOTARY•State of Nebraska
otary Public sig attire mm€ MILES •
My Ctxrun.Grp.Oct.10,2010
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 1n008
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11. Will there be any games of chance operating during the event? 0 YES 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
permit application.
12. Any other information or requests for exemptions:
13. Name and telephone number/cell 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.
��(
fit
"�lei J� 1 j�— '�CV) During — &Z_
�iti. (� Phone: Before
Print name of Event Supery sor
`` n
Si tur o ent�lup WA—
Si ./?S
Consent of Authorized Representative/Applicant..
14. 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 jr Gfhere C�J ,(fit 2. Chorized Representative/App icant Title Date
•
-1)61..( (e_
Print Name
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.
, ........ May11,2011
-a---.I
.. •A axed si us ;tun*are : - 'table
4, is: A se, •,' 0-„,--, * 1,* -4--;,- 7, 14- 1' ‘r'.•-t- ...,t;-.4 "1r 4 1 * -'4'''' 111
Form 3c III
0900005088
.._ _. _ • ,
�
County or-Do..r45►5 The foregoing instrument was acknowledged before me this
5'f-�1 �ck_n�,,� t� c�o0 9 by �ess i co— 111 �T'
da name of person acknowledged
Affix Seal
���-,e. tt GENERAL NOTARyex tate of Nebraskil
N Public signatu LORI MILES
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ignatur ividual involved with application Printed name o.f applying individual
(Spouse o dividual listed above)
State of �5 .0---
County of'�o v,Q1 S The foregoing instrument was acknowledged before me this
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—' ERAL NOTARY•State of Nebraska
otary Public sig attire mm€ MILES •
My Ctxrun.Grp.Oct.10,2010
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 1n008
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