RES 2002-1725 - SDL for music festival at MCC Fort Omaha campus August 9-10 2002 PLEASE TYPE OR PRINT APPLICATION FOR SPECIAL DESIGNATED LICENSE
'APPLICANT MUST COMPLETE NEBRASKA LIQUOR CONTROL COMMISSION .
ALL SECTIONS OF THIS FORM P.O.Box 95046,Lincoln NE 68509 .
ALL ISSUED LICENSES ARE MAILED TO LOCAL CLERKS WHERE THE EVENT IS HELD .
0 All Applications must be received in the Commission Office 10 working days(excluding holidays)prior to the date of the event
O Complete and return THE ORIGINAL WITH A DUPLICATE to the Nebraska Liquor Control Commission
O A license fee of S40(payable to Nebraska Liquor Control Commission)for each day
O LOCAL APPROVAL must be included with this application
O A Signed Statement from Local Police Chief or County Sheriff(question#12)
O 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: X Beer 14 Wine • 0 Distilled Spirits •
2. Status of the Applicant(check one) Public
0 Municipal 0 Political 0 Fine Arts 0 Fraternal .0 Religious 0 Charitable A Retail 0 Service
Corporation Corporation Museum Corporation Corporation Corporation Licensee Corporation
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3. Name and Address of Corporation,Organization or Licensee obtaining license. If licensee,give license number 1.4/
(City,State,County Number,Zip Code) And Class'(Example C/K) ae 'i2t
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6Z3
q/9/27 ?K: �/Y �6A - a L 4)4l U).S E Z G cJ,-)y 0rr��n.,,4c:
4. Address or location of premises to be covered by license,(City,County Number,Zip Code) 0'1 Ei Ra C.p M M u t V
Foy{ D1144ha Ca Ns 53DD Mil •
5.Is this PREMISE currently licensed under the Nebraska Liquor Control Act? ,❑_ YES *NO
6. Name and Address of owner or lessee and name of principal occupantof the premises for which the license is requested.
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M�yt7 COM nil_Li1%1 t CnL�e.. — D 'Tsr'l DMA sko1 co.y"\
7. Please list the name and telephone number of the primary event supervisor;who will actually be pre nt 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.
d co a co rp�—3 s it — /�0 e► � �, i -IV ill - —.ss�35
8. DATE(S)OF EVENT(If a Sunday,attach local Sunday Sales Ordinary a and hours of consumption.)
Fr.dcky - qusUS*, 9, ZoOZ tfp.Al^ 11 •3op. M
sirn94 y- AvS i,s-t• 10) 2•o aZ 12 woo. - 11 '30 P• M • ,
PLEASE INDICATE AN ALTERNATE DATE OR LOCATION IN THE EVENT OF BAD WEATHER: I}G tj c
9.Time(s)of event(example 8am to lam,this is considered one day) •
F•e,bwy y p.At i 1.30p",
• snivr4.y t'l,..a•o.J is t•30 p. ^"
FROM: TO:
10. Describe the Type of Activity to be carried on during the time period for which the license,is requested.
•Mu s;e.. Ves+:v'l 1
1 i. Provide an estimated number of attendees at this event SODO't 1000. If the number of attendees is over 250 attach a separate page
indicating the steps that will be to prevent underage persons access to alcoholic beverages.
12. PLEASE ATTACH A SIGNEDLOCAL LAW ENFORCEMENT T HAS BEEN INFORMED IN ADVANCE R COUNTY SHERIFF,WHICHEVER
IS APPLICABLE,THAT OF THIS EVENT,AND IF THEY
ARE AWARE OF ANY REASON THE EVENT SHOULD NOT OCCUR. STATEMENT IS ON FILE IN THE NEBRASKA
LIOTJOR CONTROL COittL STON'S nPFTC:F..
13. List the number of SDL's that you have applied for at this specific location in the last six months. ZQ
CONTINUE ON BACK
FORM 35.4I2t
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NEBRASKA LIQUOR CONTROL COMMISSION
APPLICATION FOR SPECIAL DESIGNATED LICENSE
UNDER NEBRASKA LIQUOR.CONTROL ACT
14. Description of the premises: 0 Inside Building 14 Outdoor Area :
Dimensions of area to be covered by license: 'x .Please draw in the space provided below,the area where
liquors will be sold and consumed. l LENGTH . WIDTH (In feet)
�� 1 h
•
If outdoor area,how will premises be separated from areas open to the general public? Fence ,Tent 0 Other(if other,please explain)
15. Is the premises to be covered by the license located within the city/village limits? O YES 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,theirwives or children? .,r YES 0 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.
0.LA.L&.P A -I- L\ c e _ C f lS 19,2 /
18. Will the premises to be covered by the license comply with all Nebraska sanitation laws? ... S ONO
19. Are there separate toilets for both men and women? ... " YES ONO
20. Other information or requests by the applicant:
21. Will there be any games of chance operating during the event? 'ES .ONO
NOTICE:Only games of chance approved by the Department o 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 foraSpeeiat
Designated License under the Liquor Control Act and is not a gambling permit application.
22.1 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. 1 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 f F-ite . L!/, Oct.?}vG.�.-re;✓1 '1
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% orized Representative/Applicant Title Date
sign
here.
Supervisor 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 desiRrrated Iicense is re•uested 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. '
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1 ACOB2. CERTIFICATE OF LIABILITY INSURANCE ; Dar`IM PA.
'D/rn
► 07/02/2001
PRaoucEa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MOORE'S INS & INVESTMENT ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2530 5. 90THH STREET HCLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
OMAHA NE 88124 ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW.
402-391-2900
INSURERS AFFORDING COVERAGE
INSURED
CLUBHOUSE LOUNGE 1INSURERA: AMERICAN STATES INSURANCE
3936 N 90TH ST. I INSURE;a;
OMAHA NE 68134 1 fNsuRE;G:
402-372-5333
IINSURE;0:I INSURER -
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 CERTIFICATED 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.
IJ,y'i I TYPE OF INSURANCE I POLICY NUMBER I POLICY EFFECTIVE I P?AY(
ACY EXPIRATION I
DATEfMM/00/M DATE(AM/OD/ UNITS
GENERAL LIABILITY • I EACrf CCCUPREO I S 500,000
X I COMMERCIAL GENERAL UABIUTY FIRE DAMAGE(Any arts tine) S 200,000
I CLAIMS MADE E OCCUR
A I 01-CE-571594-2MED oar(My one person) S
07/27/2000 07/27/2001 PERSONAL&AOv!NJURY S 500,000
•
GENER 10,000
ALAGGAEGATE S 1,000,000
GENT AGGREGATE OMIT iP(P-USES PER: PRODUCTS.COMP/CP AGO 5 1,000,000
POLCY JECT I 1 LOC
AUTOMOBILE UABIUTY
COMBINED SINGLE LIMIT
ANY AUTO (Fa accident; S
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person) S .
HIRED AUTOS
B00ILY INJURY S
NON-OWNED AUTOS (Per accaenq,.
PROPERTYer DAMAGE I S
GARAGE LIABILITY - . I AUTO ONLY-EA ACCIDENT I S
7 ANY AUTO
I� OTHER THAN ACC i S
AUTO ONLY: I AGG S
EXCESS LIABILITY
b EACH OCCURRENCEI S
OCCUR GUMS MADE I (AGGREGATE I S
IS
DEDUCTIBLE I ►S
•
I PETENTION s I S
WORKERS COMPENSATION AND I WC SYMUS Ii I OR.
EMPLOYERS'MABILITY
EL EACH ACCIDENT I S 100,000
A 01-WC-872650-Z0 07/27/2000 07/27/2001 EL DISEASE-EA EMPLOYE S 100,000
EL DISEASE-POUCYUMIT i s 500,000
OTHER
•
DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES/EXCLUSIONS ADDED SY ENOORSEMENT/SPECIAL PROVISIONS
ZERTIFICATE HOLDER I I ADDITIONAL INSURED;INSURER LETTER; CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
TO WHOM IT MAY CONCERN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR UABIUTY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
• REPRESENTATIVES.
..••:-.7,AaTH7ZED REPRESENTATIVE /
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