Nebraska > Statewide > Liquor Control Commission
Application For Cigar Bar Certification 121 - Nebraska
| Application For Cigar Bar Certification Form. This is a Nebraska form and can be used in Liquor Control Commission Statewide . |
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APPLICATION FOR CIGAR BAR 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.ne.gov Office Use MUST BE SUBMITTED WITH A $1,000 NON REFUNDABLE APPLICATION FEE PREMISE INFORMATION Trade Name (doing business as) ____________________________________________________________ Business Street Address ___________________________________________________________________ City ________________________________ County _________________________ Zip Code __________ Premise Phone Number ___________________________________________________________________ Contact Name and phone number if different from premises_______________________________________ _______________________________________________________________________________________ Class C liquor license number (if currently licensed) _________________ PREMISE 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 is the premise? __________________________________________________ 3. Does the premise 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. Form 121 Page 1 of 2 REV 10/09 American LegalNet, Inc. www.FormsWorkFlow.com 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. 3. How much was generated by tobacco and tobacco related products (not including cigarettes)? ______________________________________________________________________________ ______________________________________________________________ Print Name of Signature _____________________________________________________________ Signature of Licensee or Officer State of Nebraska County of_____________________________________________________ The forgoing instrument was acknowledge before me this ____________________________________ Date ______________________________________________________________ Notary Public Signature Affix Seal Here Form 121 Page 2 of 2 REV 10/09 American LegalNet, Inc. www.FormsWorkFlow.com
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