APPLICATION FOR ADDITION TO LIQUOR 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 Office Use Application: Must include processing fee of $45.00 check made payable to the Nebraska Liquor Control Commission or you may pay online at www.ne.gov/go/NLCCpayport Must include a copy of the lease or deed showing ownership of area to be added. This is still required even if it's the same as on file with original application Must include simple hand drawn sketch showing existing licensed area and area to be added, must include outside dimensions in feet (not square feet), show direction north. NO BLUE PRINTS May include approval from the local governing body; no addition shall be approved unless endorsed by the local governing body Check with your local governing body for any additional requirements that may be necessary in making this request for addition LIQUOR LICENSE #__________________________________CLASS TYPE________________________ LICENSEE NAME________________________________________________________________________ TRADE NAME___________________________________________________________________________ PREMISE ADDRESS______________________________________________________________________ CITY_________________________ZIP CODE_______________COUNTY_________________________ CONTACT PERSON______________________________________________________________________ PHONE NUMBER OF CONTACT PERSON__________________________________________________ EMAIL ADDRESS OF CONTACT PERSON__________________________________________________ BARCODE LABEL FORM 110 REV JULY 2015 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com What is being added? Explain the type of addition that is being requested, i.e. beer garden, adding to building _________________________________________________________________________________________ _________________________________________________________________________________________ 2. Will this addition cause the location to be within 150 feet of a church, school, hospital, home for the aged or indigent persons or for veterans, their wives, and children; or within 300 feet of a college or university campus? YES NO 1. If yes, provide name and address of such institution and where it is located in relation to the premises (Neb. Rev. Stat. 53-177)(1). Must include supplemental Form 134 found at this link: http://www.lcc.ne.gov/formsdiv.html _________________________________________________________________________________________ If proposed location is within 300 feet of a campus, the Commission may waive this restriction upon written approval from the governing body of the college or university. (Rev. Stat. 53-177)(1). Must include supplemental Form 135 found at this link: http://www.lcc.ne.gov/formsdiv.html 3. Include a sketch of the area to be added showing: existing licensed area with length & width in feet area to be added with length & width in feet direction north If adding an outdoor area explain: type of fencing height of fence length & width of outdoor area in feet 4. 12.07 Outdoor area shall mean an outdoor area included in licensed premises, which is used for the service and consumption of alcoholic liquors and which is contained by a permanent fence, wall or other barrier approved by the Commission and shall be in compliance with all building and fire, or other applicable local ordinances. Rule Chapter 2­012.07 I acknowledge under oath that the premises as added to comply in all respects with the requirements of the act. Neb Rev Stat §53-129 ________________________________________________ Signature of Licensee or Officer State of Nebraska County of _____________________________________ The foregoing instrument was acknowledged before me this __________________________________________ by __________________________________________________ Date name of person acknowledged (individual(s) signing document) Affix Seal __________________________________________ Notary Public signature FORM 110 REV JULY 2015 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com