Liquor License Transfer_The GymABD Licensing -Applicant
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_~ Applicant Applicant BW0092902, THE GYM, Dubuque
m Transfer Premise After completion click on the NEXT link to continue to the next screen, or the BACK link to return to the previous screen.
New Premise Location Information The navigation links on the top may also be used to move around the application.
Applicant Signature Name of Applicant: Revive, InC. (Sole Proprietorship, Partnership, Corporation, etc.)
Dram Cert Name of Business (DlB/A): THE GYM
a Local Endorse Address of Premise: 1097 Elm Street
Address Line 2:
City: Dubuque
County: Dubuque
Zip: 52001
Business Phone: (563) 566-6496 Cell !Home Phone: (563) 451-2
~ Same Address
Mailing Address: 1097 Elm Street
Mailing Address Line 2:
City: Dubuque State: Iowa
Zip: 52001
Contact Name: Adam Howland
Phone: (563) 451-2511 Email Address: reviveinC@I
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Phone: (866) 469-2223
https://eicensing.iowaabd.com/Applicant.aspx 10/01 /2008
ABD Licensing -Transfer Premise
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A. Applicant Transfer Premise BW0092902, THE GYM, Dubuque
Transfer Premise After completion click on the NEXT link to continue to the next screen, or the BACK link to return to the previous screen.
New Premise Location Information The navigation links on the top may also be used to move around the application.
Applicant Signature Licenses may be transferred from one location to another, but only within the boundaries of the current approving Local ~
Dram Cert Transfer Application and all supporting documentation shall be approved by the Local Official and forwarded to the Iowa
Beverages Division before the event takes place. All selling and serving of alcoholic beverages must cease at the original
Local Endorse location during the period of the transfer. NOTE: If requesting a permanent transfer, an amended license will be forwarder
Official. If requesting a temporary transfer, a letter of permission will be forwarded to the Local Official.
Name of Applicant: Revive, Inc.
Name of Business (D!B!A): THE GYM
Address of Premise: 1097 Elm Street
Address Line 2:
City: Dubuque County: Dubuque Zip: 52001
New Premise Address: 1000 Jackson st
New Premise Address Line 2:
State:
City: Dubuque ~ Iowa Zip: 52001
(: Temporary Transfer (24 hours through 7 days}
Beginning Date: 10/11/2008
r Permanent Transfer
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Phone: (866)469-2223
Beginning Date: ~®
Ending Date: 10/11/2(
Ter
https://eicensing.iowaabd.com/TransferPremise.aspx 10/01/2008
ABD Licensing -New Premise Location Information
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Keg Registration
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=`' Applicant _.._
New Premise Location Information BW0092902, THE GYM, Dubuque
Transfer Premise After completion click on the NEXT link to continue to the next screen, or the BACK link to return to the previous
M New Premise Location Information screen.
The navigation links on the top may also be used to move around the application.
Applicant Signature
Dram Cert ~- # of Bathrooms:
v I' Number of floors where alcoholic beverages will be sold, served, consumed and stored.
Local Endorse
Indicate how you have control of premises (Permanent Transfers Only):
C' Own
f Lease
Submit to the Local Authority a signed copy of the lease/rental agreement for the license period or signed final sales
contract or warranty deed.
Submit to the Local Authority a sketch on 81/2 x 11"white paper of the proposed premises showing all areas and
floors where alcoholic beverages will be sold, served, consumed and stored. Indicate all entrances and exits, location
of bar, back bar and bathrooms. If Applicant has Outdoor Service Area Privilege, please include in the sketch its
relationship to the licensed premises.
Outdoor Service ("~~
Area Dates (if From: I MMIDD/YYYY To: ~ MM(DD/YYYY
applicable):
Dates shall correspond with requested outdoor service areas.
On-Premise
Applicant's Only:
Yes ~ Is the premise furnished with tables and seats to accomodate a minimum of 25 persons at one
time?
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Phone: (866) 469-2223
https://eicensing.iowaabd.com/NewPremiseLocationInformation. aspx
Terms of Service
10/0l /2008
ABD Licensing -Applicant Signature
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Applicant
= Transfer Premise
New Premise Location Information
Applicant Signature
'~ Dram Cert
Local Endorse
Applicant Signature BW0092902, THE GYM, Dubuque
Page 1 of 2
Complete the information below and click Finish to complete the application
Note that the license fees will only be withdrawn from accounts after the ABD approves the license.
This application must be completed by a person listed in the Ownership Section.
I hereby declare that all information contained in the Application is true and correct. I understand that
misrepresentation of material facts in the Application is a crime and grounds for denial of the license or permit
under Iowa law. I further understand that, as a condition of recieving a license, the licensed premise is subject to
inspection during business hours by appropriate local, state and federal officials.
NOTE: The Applicant's Name must match one of the owner's names from the Ownership screen.
Applicant's Name: TAMMY FORD Date: 10!01/2008 MM/DD/YYYY
Tentative effective date: 10/11/2008 MM/DDIYYYY
Phone: (866) 469-2223
Please print a copy of this page for your records before clicking the "FINISH" button.
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Terms of Service
https://eicensing.iowaabd.com/ApplicantSignature.aspx 10/01 /2008