RES 2004-0364 - SDL for beer garden at Zesto's June 23-28 2004 PLEASE TYPE OR PRINT
APPLICANT MUST COMPLETE
'ALL SECTIONS OF THIS FORM
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APPLICATION FOR SPECIAL DESIGNATED LICENSE
Nebraska Liquor Control Commission
P.O.Box 95046,Lincoln,NE 68509
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 holidays)prior to the date of the event
❑ Complete and return THE ORIGINAL WITH A DUPLICATE to the Nebraska Liquor Control Commission
El A license fee of$40 (payable to Nebraska Liquor Control Commission)for each day
❑ LOCAL APPROVAL must be included with this application
❑ A Signed Statement from Local Police Chief or County Sheriff(question#12)
❑ NON PROFIT CORPORATION MUST include a letter from the IRS declaring that the corporation is exempt from payment of
federal income taxes, or a copy of the corporation's federal income tax return,as filed with the IRS,or a statement(Page 3)
signed by an officer of the corporation declaring that the copy of the tax return is a true and correct copy as filed with the IRS
1. Type of Beverage(s)to be served: ® Beer ®Wine ® Distilled Spirits
2. Status of the Applicant (check one)
❑ Municipal ❑ Political ❑ Fine Arts ❑ Fraternal El Religious ❑Charitable
® Retail El Public Service
Corporation Corporation Museum Corporation Corporation Corporation Licensee Corporation
3. Name and Address of Corporation, Organization or Licensee obtaining license(City,County Number, State,Zip Code)
777,Inc., 777 No. 114th Street, Omaha,NE 68154(Douglas County)
If licensee, give license number and Class: C 42681
4. Address or location of premises to be covered by license(City, County, Number,Zip Code)
Ze s} I
0 S 3901 So. 13th Street, Omaha,NE 68112(Douglas County)
5. Is this PREMISES currently licensed under the Nebraska Liquor Control Act? ❑ Yes ® No
6. Name and Address of owner or lessee and name of principal occupant of the premises for which the license is requested.
Gabriel Barajas, 3901 So. 13th Street, Omaha,NE 68112
7. Please list the name and telephone number of the primary event 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 2.
Patty Ferguson, 393-1610 or 630.1720
8. DATE(S)OF EVENT(If a Sunday, attach local Sunday Sales Ordinance and hours of consumption.)
23 to �ur�L28, 2004
Please indicate an alternate date or location in the event of bad weather:
9.Time(s)of event(example 8 am to 1 am,this is considered one day) I -'i
FROM: 8:00 a.m. TO: 1:00 a.m. )2��c!✓t -I-C)
10. Describe the type of Activity to be carried on during the time period for which the license is requested.
Beer garden �C f) c
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11. Provide an estimated number of attendees at thi ..vent 500. If the number of attendees is over 250 attach a separate page indicating
the steps that will be taken to prevent underage persons access to alcoholic beverages.
12. PLEASE ATTACH A SIGNED STATEMENT FROM YOUR 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.
13. List the number of SDL's that you have applied for at this specific location in the last six months. 0
CONTINUED ON PAGE TWO
NEBRASKA LIQUOR CONTROL COMMISSION
APPLICATION FOR SPECIAL DESIGNATED LICENSE • -
UNDER NEBRASKA LIQUOR CONTROL ACT
14. Description of the premises: ❑ Inside Building ® Outdoor Area
Dimensions of area to be covered by license: 100'x 150'(Length x Width). Please draw in the space provided below,the area where liquors
will be sold and consumed.
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�`--` The entire area will be fenced in.
Tents are annrox . 17 ' x 17 ' and
2 Lsrp
If outdoor area, how will premises be separated from areas open to the general public?Z Fence ® Tent I1-Other(please explain)
15. Is the premises to be covered by the license located within the city/village limits? ®YES ❑ NO
16. 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? ❑YES ® NO
17. Explain how alcoholic liquors will be purchased by the licensee. If purchased from a retail licensee, please give the name and license
number.
Through wholesaler •
18.Will the premises to be covered by the license comply with all Nebraska sanitation laws? ®YES ❑ NO
19.Are there separate toilets for both men and women? ®YES ❑ NO
20. Other information or requests by the applicant:
21.Will there by any games of chance operating during the event?❑YES ® NO
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. This is only an application for a
Special Designated License under the Liquor Control Act and is not a gambling permit application.
22. I declare that I am the authorized a 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 �iL/ } (Y/�/lc��� f Xi7-0V
Authorized Representative/Applicant Title Date
Sign /
here `��`E 1�I�G 4 7,7 fi y
upervisor Title Date
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.
Supplement—Application for Special Designated License
Licensee: 777, Inc.
Event Date: June 18 to 28, 2004
11. Will have paid security people on staff at all times to check identification
and issue wrist bands. There will be perimeter fencing.
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