APPLICATION FOR CIGAR SHOP CERTIFICATION 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 MUST BE SUBMITTED WITH A $1,000 NON REFUNDABLE APPLICATION FEE, check made payable to the Nebraska Liquor Control Commission or you may pay online at www.ne.gov/go/NLCCpayport PREMISES INFORMATION Trade Name (doing business as) ____________________________________________________________ Business Street Address ___________________________________________________________________ City ________________________________ County _________________________ Zip Code __________ Premises Phone Number ___________________________________________________________________ Contact Name and phone number if different from premises_______________________________________ _______________________________________________________________________________________ Class C liquor license number (if currently licensed) _________________ PREMISES DESCRIPTION AND DIAGRAM OF STRUCTURE 1. Do you serve food? YES NO If yes, you will not qualify for this certification 2. How many square feet are the premises?_________________________________________________ 3. Do the premises have a walk in humidor? YES NO YES NO 4. Does the humidor have a humidification and temperature control system? 5. How many square feet is the humidor? ________________ Provide photos of the humidor Office use only PAYMENT TYPE ______________________ AMOUNT: ______________________ Received: ______ American LegalNet, Inc. www.FormsWorkFlow.com BARCODE FORM 121 REV JUNE 2015 PAGE 1 OF 2 BUSINESS INFORMATION 1. Has your business been cited for any liquor license violations? YES NO If yes, explain _________________________________________________________________________________ _________________________________________________________________________________ 2. What was your total revenue for the business last year? _________________________________ Enclose copies of financial statements showing total sales vs. sales of tobacco and tobacco related products. How much was generated by tobacco and tobacco related products (not including cigarettes)? ______________________________________________________________________________ 3. APPLICANT HEREBY DECLARES THAT No person under (21) twenty-one years of age shall be allowed to smoke or purchase any product in the cigar shop. Licensee shall post a sign on all entrances to the cigar shop, on the outside of each door, in a conspicuous location slightly above or next to the door, with the following statement: "SMOKING OF CIGARS AND PIPES IS ALLOWED INSIDE THIS BUSINESS. SMOKING OF CIGARETTES IS NOT ALLOWED." Effective November 1, 2015, all employees must sign a waiver acknowledging they will be exposed to second-hand smoke. A copy of this waiver must be filed with the Nebraska Liquor Control Commission. These forms will be available on our website at a later date. _________________________________________________________ Signature of Applicant May be signed by anyone named on the liquor license In compliance with the ADA, this application is available in other formats for persons with disabilities. A ten day advance period is required in writing to produce the alternate format. FORM 121 REV JUNE 2015 PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com