RES 2006-0753 - SDL for beer garden at Dundee Dell August 25-26 2006 I • 4
APPLICATION FOR SPECIAL DESIGNATED LICENSE
LICENSEE
NEBRASKA LIQUOR CONTROL COMMISSION
P.O.Box 95046
Lincoln NE 68509-5046
ALL ISSUED LICENSES ARE MAILED TO LOCAL CLERKS WHERE THE EVENT IS HELD
❑All Applications must be received in the Commission Office 10 working days(excluding weekends and holidays)prior to the
date of the event
❑Complete and return THE ORIGINAL WITH A DUPLICATE to the Nebraska Liquor Control Commission
❑A license fee of$40(payable to Nebraska Liquor Control Commission)for each day(no fees if caterer)
❑APPROVAL FROM CITY,VILLAGE OR COUNTY CLERK must be included with this application
❑A Signed Statement from Local Police Chief or County Sheriff
1. Type of Beverage(s)to be served or consumed: jZfBeer Wine 516istilled Spirits
2. License number and class `. j!a 0// )Retailer OCaterer
(i.e.I/K-12345)
3. Name and Address of Applicant(as listed on liquor Iicense)(City,County,Zip Code)
4. Address or location of premises to be covered by license,(street,city,county,zip code)
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5. Address of where alcohol is to be stored if other than at location listed in question#4 above
/6. Name,address,phone number/cell` phoneho/ number of owner or lessee of premises for which the licens ,isrequested YGZ
1 (�` l i Cam/V�e J f G 7!I/$ LI ei l G! S
7. DATE(S)OF EVENT(If Sunday,attach Sunday sales ordinance)no more then six(6)consecutive days per application
a)If alternate date is requested please list below:(must be approved at local level prior to event)
ALTERNATE DATE:
b)If alternate location is requested please list below:(must be approved at local level prior to event)
ALTORNA E 57'_ S a Gct( . .
8.Time(s)of event(example 8:00 am to 1:00 am,this is considered one day) .
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9. Describe
type of activity to be carried on during the timeperiod for which the license is requested
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10. Provide an estimated number of attendees at this event /2 CCJ . If the number of attendees is over 150 attach a separate page
indicating the steps that will be taken to prevent underage persons access to alcoholic beverages.
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I I. Attach a signed statement from your local police chief or county sheriff, whichaer 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
•
12. Description of the premises: Inside Building outdoor Area
Dimensions of area to be covered by license: ...2 SZ x /00 . Please draw in the space provided below,the area where
liquors will be sold and consumed. LENGTH WIDTH (In feet)
If outdoor area,how will premisesj be separ ted from areas ope to the general public?
'Fence,type of fence h r�7 /9 e" e-f c
Tent
Other(if other,please explain) " 72 S�
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13. Is the premises to be covered by the license located within the city/village limits? EYES 0 NO
14. Is the premises to be covered by the license within 150 feet of any church,school,hospital,or home for the aged or indigent persons or for
veterans,their wives or children? ... OYES NO
15. Is the premises to be covered by the license within 300 feet of any university or college campus OYES IRYNO
16. Explain how alcoholic liquors will be purchased by the licensee. If purchased from a retail licensee, please give the name and license
number.
Check here if for consumption only gi (no purchases or sales,i.e.byob)
17. Will the premises to be covered by the license comply with all Nebraska sanitation laws? EYES NO
18. Are there separate toilets for both men and women? EYES NO
19. Other information or requests for exemptions,must be requested and approved prior to event:
20. Will there be any games of chance operating during the event?OYES 'ONO If so,describe activity
NOTICE: 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.
21.Name and telephone number/cell phone number of immediate supervisor, who will actually be present at the location of the event when
it occurs,that can be contacted by law enforcement before and during the event, and who is responsible for ensuring that any applicable laws,
ordinances,rules and regulations are adhered to. Supervisor must sign on page 3.
ESP 7 v y, 772
22. 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
4.
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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
supervisedby persons i tly responsible to the older of this Special Designated License.
here L
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l Authorized Representative/Applicant Title Date
rP i/rde / /• 6 c1j- ' /
Print Name
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sign /,,�/
here /r/IM i--0Vre4/ i t&EK �Lt U,
u rvis Title Date
I6 0-Alo/1✓t ar,J
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.
In Compliance with ADA,this form is available in
other formats for persons with disabilities.
A ten day advance period is requested in writing
to produce the alternate format.
Rev 7/04
35.4121 rt
ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID DATE(MMIDDrYYYY)
1
DUNDE-2 04/26/06
PRODUCER 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 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURFRA EMC Insurance Companies 21415
Dundee Memorial Park Neighbor- INSURER B:
hood Association INSURER C:
c/o Dan Rock
8805 Indian Hills Dr Ste 280 INSURER0:
Omaha NE 68114
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TNT POLICY NUMBER DATE(MMIDD/rr) DATE(MMIDDIYY) LIMITS
XPIHATIUN
LTR NSRO TYPE OF INSURANCE
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
'uEMIS i EaOcc D $100,000
A X X COMMERCIAL GENERAL LIABILITY 2D2832907 05/14/06 05/14/07 PREMISES(Eaocaaence)
CLAIMS MADE I X l OCCUR MED EXP(Any one person) a5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE a2,000,000
GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000
—1 POLICY I-I!& n LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $300,000
A - ANY AUTO 2E2832907 05/14/06 05/14/07 (Ea accident)
ALL OWNED AUTOS BODILY INJURY $
(Per person)
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY $
(Per accident)
X NON-OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
VVL SIAILU- UIFF
WORKERS COMPENSATION AND TORY LIMITS ER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $
II yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
City of Omaha is hereby named as Additional Insured for Dundee Days, August
26, 2006 at 5007 Underwood Avenue, Omaha NE.
CERTIFICATE HOLDER CANCELLATION
CITY001 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
City of Omaha IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
1819 Farnam Ste 300
Omaha NE 68183 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
_David R. Chastain, CLU,CPCU
ACORD 25(2001/08) @ ACORD CORPORATION 1988
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A, NF8Cit o Omaha Nebras a �1I' 'y _i,7
1819 Farnam—Suite LC 1 ®A'� r c
Omaha, Nebraska 68183-0112 0 = - ,_
Buster Brown (402) 444-5550 ro
City Clerk FAX (402) 444-5263 oTFo FEBRvt►�`4
June 27, 2006
Dell Enterprises, Inc. Application for Special Designated
Dba "Dundee Dell" Licenses on August 25 & 26, 2006
5007 Underwood Avenue Music to end at 12:00 midnight
Omaha, NE 68132
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application for a Special Designated liquor license has been set for July 11,
2006.
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 to the Nebraska Liquor Control Commission.
Since -ly yours,
Buster Brown
City Clerk
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