RES 2016-1140 - SDL to Dr Jack's Drinkery for beer garden APPLICATION FOR SPECIAL
DESIGNATED LICENSE
NEBRASKA LIQUOR CONTROL COMMISSION - 1 ; I L. I.-
301 CENTENNIAL MALL SOUTH
PO BOX 95046
LINCOLN,NE 68509-5046 2016 n _9 r? 1: C9
PHONE:(402)471-2571
FAX:(402)471-2814
Website:www.lcc.ne.gov/
DO YOU NEED POSTEIt ''YiS°NO
RETAIL LICENSE HOLDERS O
NON PROFIT APPLICANTS 0
Non Profit Status (check one that best applies)
Municipal0Political°Fine Arts0Fraternal O .eligiousOharitableOPublic Service°
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Bee inSOistilled Spirits C
2. Liquor license number and class(i.e. C-55441) CK-102004
(If you're a nonprofit organization leave blank)
3. Licensee name (last, first,), corporate name or limited liability company (LLC)name
(As it reads on your liquor license)
BrassKnocker INC. �,
NAME: bU, i( � � tc_\c\t1'( \`
3012 N 102nd St
ADDRESS:
Omaha 68134
CITY ZIP
4, Location where event will be held; name, address, city, county, zip code
Dr Jacks
BUILDING NAME
3012 N 102nd St Omaha
ADDRESS: CITY
68134 Douglas
ZIP COUNTY and COUNTY
a. Is this location within the city/village limits? YE'0 00
b. Is this location within the 150' of church, school, hospital or home
for aged/indigent or for veterans and/or wives? YESJTO®
c. Is this location within 300' of any university or college campus? YESQ1
.0
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5, Date(s) and Time(s) of event (no more than six (6)consecutive days on one application)
1 atc7-16 Date Date Date Date Date
Hours Hours Hours Hours Hours Hours
From From From From From From
2pm-tam
To To To To To To
a. Alternate date:
b. Alternate location:
(Alternate date or location must be specified in local approval)
6. Indicate type of activity to be carried on during event:
°Dance °Reception °Fund Raiser OBeer Garden O Sampling/Tasting
OOther
7. Description of area to be licensed
Inside building, dimensions of area to be covered IN FEET x
(not square feet or acres)
*Outdoor area dimensions of area to be covered IN FEET 150 x 300
*SKETCH OF OUTDOOR AREA (or attach copy of sketch) (sample sketch)
• tdoor are ap
w will premises be enclosed?
0 ence; snow fence Dhain link ❑cattle panel
other
Tent
8. How many attendees do you expect at event? 100
9. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from
obtaining alcohol beverages. (Attach separate sheet if needed)
10. Will premises to be covered by license comply with all Nebraska sanitation laws? YESO O°
a. Are there separate toilets for both men and women? YES 0 00
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11. Retailer: Will you be purchasing your alcohol from a wholesaler? YES NO 0
Non-Profit: Where will you be purchasing your alcohol?
Wholesaler® Retailer,® Both Ea BYO El
(includes wineries)
1:2. Will there be any games of chance operating during the event? YESONO0
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.
13. Any other information or requests for exemptions:
14. Name and telephone number/cell phone number of immediate supervisor. This person will be at
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. PLEASE PRINT LEGIBLY
Derek Wallen
Print name of Event Supervisor
Signature of Event Supervisor
402-708-1039 402-708-1039
Event Supervisor phone: Before During
Email address Derekwallen @gmail.cor
Consent of Authorized Representative/Applicant
15. 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.
President
here
Authorized Representative/Applicant Title Date
Derek Wallen
Print Name
This individual must be listed on the application as an officer or stockholder unless a letter has been filed appointing an individual
as the catering manager allowing them to sign all SDL applications.
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.
FORM 108
REV Jun-13
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No. \N°1
The Brassknocker, Inc., dba "Dr Jack's
Drinkery", 3012 North 102nd Street, requests
permission for a Special Designated License for
a beer garden.i _t eir-par-kiRg let at 12- ort
t on August 27, 2016 from 2:00
p.m. to 2:00 a.m. with music until 11:00 p.m.
08-16-16;cj
/ Y
RECEIVED
Presented to Council:
August 16, 2016 - O-\c;,R to
C,.Art\i - (Sal r LA 1 0
Buster Brown
City Clerk