RES 2016-0788 - SDL to Perry's Place for concert July 22-23, 2016 APPLICATION FOR SPECIAL
DESIGNATED LICENSE
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.nebraska.gov/
Email Applications: michelle.porter@nebraska.gov
DO YOU NEED POSTERS? YES)' NO_
NON PROFIT APPLICANTS
(Check one that best applies)
Municipal Political Fine Arts Fraternal Religious Charitable Public Service
LIQUOR LICENSE HOLDERS
Liquor license number and class (i.e. C-55441)
COMPLETE ALL QUESTIONS
1. Type of alcohol to be served and/or consumed: Beer 1, Wine r Distilled Spirits /`
2. Licensee name (last, first,), corporate name or limited liability company (LLC)name
(As it reads on your liquor license)
NAME:
ADDRESS: rl �0.pCar . rgt3t {
CITY ,r(i"°.k,-,.,;-, ZIP (c\'r
3. Location where event will be held; name,address, city, county, zip code
BUILDING NAME `At.A21z
ADDRESS: `"I 1� @ �� � ti �� '�� CITY(..). vi .,h �,^g
ZIP ` r COUNTY and COUNTY#
a. Is this location within the city/village limits? YES"),<NO
b. Is this location within the 150' of church, school, hospital or home
for aged/indigent or for veterans and/or wives? YES NOS/'
c. Is this location within 300' of any university or college campus? YES NO X
FORM 108
REV JAN 2016
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4. Date(s) and Time(s)of event(no more than six (6)consecutive days on one application)
Date Date Date Date Date Date
Hours H' urs Hours Hours Hours Hours
From From From From From From
To To To To To To
a. Alternate date: l;,b ,
gyp '
b. Alternate location:/ \
(Alternate date or location must be specified in local approval)
5. Indicate type of activity to be carried on during event:
Dance Reception Fund Raiser Beer Garden Sampling/Tasting
Other C c,v(z'iIi=
6. 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 i tlo x lc` ( )
*SKETCH OF OUTDOOR AREA(or attach copy of sketch) (sample sketch)
If outdoor area, how will premises be enclosed?
Fence; )K)snow fence chain link Incattie panel
_other
Tent
7. How many attendees do you expect at event? )
8. If over 150 attendees. Indicate the steps that will be taken to prevent underage persons from obtaining
alcohol beverages. (Attach separate sheet if needed)
e 6
': t a t`� e; i-0 ` r'=r^o '�wa.v : :_ .. -.1�rZ L. �v^' ii'. ' C(r �_
9. Will premises to be covered by license comply with all Nebraska sanitation laws? YE n 0 L
a. Are there separate toilets for both men and women? YE. E,NO n
l / / I
6! ! / "� ✓✓ 1 i 1 L
FORM 108
REV JAN 2016
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10. Where will you be purchasing your alcohol?
Wholesaler, Retailer Both BYO
(includes wineries)
11. Will there be any games of chance operating during the event? YES< NO_
If so, describe activity 1 : vc .
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 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
Print name of Event Supervisor Aet,,K � �
Signature of Event Supervisor ;;. ,
Event Supervisor phone: Before"` %.)-L..p '� y, During G: )-- S' -(e
Email address. , {' ,ry
Consent of Authorized Representative/Applicant
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 responsible to the holder of this Special Designated License.
sign
here ` cts— - l '
Authorized Rep ser eritive/Applicant Title Date
Print Nam
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
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Cthj thraskçzo�AHA, �
1819 Farnam - Suite LC 1
Omaha, Nebraska 68183-0112 n _ 14 if - '^
Buster Brown (402) 444-5550 �'� = .; _ ,v.
City Clerk FAX (402) 444-5263
TFD FEB01'
May 26, 2016
JAX, Inc. Application for Special Designated
Dba "Perry's Place" License for July 22-23, 2016 with
9652 Mockingbird Drive music until 12:00 midnight
Omaha, NE 68127
Dear Liquor License Applicant:
This letter is notification that a hearing before the Omaha City Council on your
application(s) for a Special Designated liquor license has been set for
June 7, 2016
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 or his/her representative 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(s) to the Nebraska Liquor Control Commission.
Sincerely yours,
.;ram -
Buster Brown
City Clerk
BJB:clj
No. 7d 7
JAX, Inc., dba "Perry's Place", 9652
Mockingbird Drive, requests permission for a
Special Designated License for a concert on
July 22-23, 2016 from 12:00 noon to 12:00
midnight with music until 12:00 midnight.
06-07-16;cj '/
\
RECEIVED
Presented to Council:
June 7, 2016 - Approved -6
Buster Brown
City Clerk