RES 2008-0815 - SDL for beer garden at Dundee Dell August 23 2008 APPLICATION FOR SPECIAL
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/
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C Include approval from the City, Village or County Clerk where the event is to be held
Include signed statement from the local law enforcement (see question#8)
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)
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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' /(g/K
3. Licensee name (last, first,middle), Corporate name, Limited Liability Company(LLC)
NAME: p,7/
f/.7 v 771 3 e-s.ITA c
ADDRESS: 5 GGapiji-,i ,e)6.e,ci COUNTY7/ l 4
v113 7
Je D-e_ I /3 —
4. Location where event will be held; name, address, city, county, zip code r-�
ADDRESS: oe)7aktiv,,,„,... ve'( � e/ COUNTY )0Ge 1 c
a. Is this location within the city/village limits? •15YES❑ NO
b. Is this location within the 150' of church, school, hospital or home
aged/indigent or for veterans their wives? ❑ YES' NO
c. Is this location within 300' of any university or college campus? ❑ YESNO
5: Date(s) and;Time(s)of:event(no more tjien`":s x • ):`co• nsecutive'days.on one'application).
Date 4 Q.23,wog Date Date Date Date Date
Hours Fr m Hours From Hours From Hours .From Hours From Hours From
6,'GC, ,/
/xi/4,f�To To To To To To
a. Alternate date:
b. Alternate location:
(alternate date or location must be approved by local and law enforcement)
6. Indicate type of activity to be carried on during event
O Dance ❑ Reception 0 Fund Raiser Beer Garden ❑ Sampling/Tasting 0 Other
7. Description of area to be licensed
0 Inside building, dimensions of area to be covered INFEET ? - x /6-C`
Name of building (not square feet or acres)
X.Outdoor area dimensions of area to be covered INFEET 2 ,- x l cv
(not square feet or acres)
If outdoor area, how will premises be enclosed
fence, type of fence
❑ tent
❑ other, explain )� k•S C_ ,\ . ' I l l� i; 0I /(3ii
*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 occu ''' ' ''. '-' '' '-''' ''''''...---' '''' ' ' ' -'
r
; I .
9. Indicate the steps that will be taken to prevent underage persons from obtaining alcohol beverages.
10. Will premises to be covered by license comply witli all Nebraska sanitation laws? W,4/vi° 4'1
❑ YES ❑ NO /'
a. Are there separate toilets for both men and women? AYES 0 NO
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11. Will there be any games of chance operating during the event? ❑ 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.
l �G� / Phone: Before ? -757f During 14
Print name of Event,.Supervisor
••.
Signature/of Event Supervisor
C.
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 to the holder of this Spe ial Designated License.
sign 11
here / ��`f' r. l%
Authorized Representative/ pplicant Title Date
/ c •
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.
ACORD, ' CERTIFICATE OF LIABILITY INSURANCE DUDE z"I DATE(IBMIDDntiYY)06/02/08
PRoOuCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chastain-Otis Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
9394 West Dodge Road Suite 150 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Omaha NE 68114-3319
Phone:402-397-2500 Fax:402-397-2467 INSURERSAFFORDINGCOVERAGE NAIC6
NSIm® NWRMA EMC Insurance Companies 21415
INSURER E:
ndee Memorial Park Neighborh Dundee
o Dan Rock
05 Indian Hills Dr Ste 280 INSURER D:
Omaha HE 68114
INSURER E:
COVERAGES
THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSN TO hIE MHO NAMED ABOVE FOR DE POLICY PO&O IQICATED.NOTYYIIIHSTNDNG
ANY JB EME NT.TEAM OR CONDITION OF ANY CONTRACT OR OTTER 000U ENT WITH RESPECT TO WHICH THIS CERTIFICATE WAY BE I&OLEO OR
WAY PERTAN,THE MISMANCE AFFORDED BY DE POLICES DESCREEOIBLEN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND COIORIONS OF SUCH
POLICIES.AGGREGATE LIME SWAIN MAY HAVE BEEN(EDUCED BY PAD CLAIMS.
LIRWISr HMG TY►E OF INSURANCE POLICY t1UIBER 1241..YolguoiltelmiTt
BATE(MIIOBA Y LAWS
OEBIAL LIABILITY EACH OCCURRENCE $1,000,000
A X . X COmERC1PLGENERALUABLITY 2X2832909 05/14/08 05/14/09 P " "occur
CLAW MADE X OCCUR MEDEXP(PFIY Damn) $S,000 00
PER.SO.L$AN Kure s 1,000,000
GENERAL A GATE s2,000,000
GENL AGGREGATE LIMIT NPPLIES PER PRODUCTS-°A PP AGO $2,000,000
)P UCY n FLOC
AUTGMMOBLELIABILITY
mimeo ANY ALTO (Ee ) Omit S
ALL OAMEDAUTOS BODILY MEW
SCHEDULED AUTOS (Per mum)
HIRED AUTOS BODILY NARY
NON-OWNED AUTOS (Per suckled)
PROPERTY OM/AGE
(Peroxidant)
GARAGE UABLRY AUTO OIIY-EA ACCIDENT $
ANY AUTO OTHER uw EA ACC i
AUTO ONLY: AGG $
EXCE SIUMBRELLA UABLTTY EACH OCCURRENCE $
OCCLR n aAIGS WOE AGGREGATE $
-1 DEDUCTIBLE $
RETENNON $ $
WORKERS COMPENSATION AND ITOVRY LIHAMIIS I I Ug-
EMPLOYERS'uABLRY
EL EACH ACCIDENT
ANY PROPRETOR/PARITEREXECUINE
$
ccFICERAEMBER OCCLUDED? E.L.DISEASE-EA EAROYEE $
If yyeess lesafbe under
SPEr1AI PROVISIONS bri
m
El.DISEASE-POLICY MT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEMCLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
City of Omaha is hereby named as Additional Insured for Dundee Days, August
23, 2008 at 5007 Underwood Avenue, Omaha NE.
CERTIFICATE HOLDER CANCELLATION
ciriooI SHOULD ANY OF THE ABOVE DESK POLICES BE CANCELLED BEFORE THE OGPRATION
DATE THEREOF,THE ISSUING NEARER WLL ENDEAVOR TO MAL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIE LET,BUT FAILURE TO DO SO SHALL
City of Omaha rep011E NO OBLIGATION OR LIABILITY Of ANY HIND UPON THE INSURER ITS AGENTS OR
1819 Parnam Ste 300
Omaha NE 68183 REPRESENTATIVES.
AUTHORIZED REP ENTATsE
David R. Chastain, CLU,CPCU
ACORD 25(2001/08) ACORD CORPORATION 1988
IMPORTANT
Ifthecertificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. A statement
po icy( ) e
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may
require an endorsement A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon.
•
•
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ACORD 25 2001/08
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t on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon.
•
•
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ACORD 25 2001/08