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NEBRASKA LIQUOR CONTROL COMMISSION <br /> ( PitONE:(402)471-2571 <br /> ' Website: www.Icc nebraska.gov <br /> Special Designated License <br /> Local Recommendation (Form 200) <br /> Applications must be entered on the portal after local approval-no exceptions <br /> Late applications are non-refundable and will be reiected <br /> Kinkaider Brewing Co. <br /> Retail Liquor License Name or*Non-Profit Organization(*Must include Form#201 as Page 2) <br /> 316 No. Pine St. Grand Island Ne 68810 <br /> Retail Liquor License Address or Non-Profit Business Address <br /> 121566 <br /> Retail License Number or Non-Profit Federal ID# <br /> Consecutive Dates only 9/11/18 9/12/1E 9/13/16 <br /> Event Date(s): <br /> Event Start Time(s): 9am 9am 9am <br /> Event End Time(s): 11pm 11pm 11pm <br /> Alternate Date: n/a <br /> Alternate Location Building&Address: <br /> Event Building Name: Outdoor Beer Garden at Husker Harvest Day <br /> Event streetAddress/city: 9000 W. Husker HWY. Wood River Ne 68883 <br /> Indoor area to be licensed in length&width: X <br /> Outdoor area to be licensed in length&width: 75 X 65 (Diagram Form#109 must be attached) <br /> Type of Event: Outdoor farm show Estimate#of attendees: 1000 <br /> Type of alcohol to be served: Beer X Wine X Distilled Spirits X <br /> (If not marked,you will not be able to serve this type of alcohol) <br /> Event Contact Name: Delene Dilsaver Event Contact Phone Number:402-239-7369 <br /> Event Contact Email: gi @kinkaider.com <br /> *Signature Authorized Representative. _ - 'rinted Name Delene Dilsaver <br /> I declare that lam the authorized representative of the above named license applicant and that the statements made on this application are true to the <br /> 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 <br /> to waive any rights or causes of action against the Nebraska Liquor Control Commission,the Nebraska State Patrol or any other individual releasing <br /> 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 <br /> 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 <br /> holder of this Special Designated License. <br /> *Retail licensee-Must be signed by a member listed on permanent license <br /> *Non-Profit Organization-Must be signed by a Corporate Officer <br /> Local Governing Body completes below: <br /> The local governing body for the City/Village of OR County of approves <br /> the issua l a Special P igna. : icense as requested above. (Only one should be written above) <br /> ��_ r?— z- / —( 8 <br /> Lo :1 Governing Bo irized Signature Date <br />