Liquor Lic.Transfer Busted LiftNORTH POINTE INSURANCE COMPANY
ATTACHING TO AND FORMING PART OF POLICY NO. NPLL67143
NAMED INSURED: Davey Robertsons Public Bar
DBA: The Busted Lift
ENDORSEMENT NO. 1
It is agreed and understood that this endorsement transfers your Liquor Liability
coverage to a secondary location for the dates specified.
Location: Louis Murphy Park
2200 Bunker Hill Rd.
Dubuque, Iowa
52001
Date(s): 10-13-01 to 10-14-01
This endorsement is a part of your policy and takes effect on the date noted above
unless otherwise stipulated.
EFFECTIVE DATE:
10-13-01 to 10-14-01
AUTHORIZED SIGNATURE
THE DECLARATIONS, INSURING AGREEMENTS, DEEINATIONS, EXCLUSIONS,
AND CONDITIONS OF THIS POLICY OTHERWISE REMAIN UNCHANGED.
9/18/2001 kj
NORTH POINTE INSURANCE COMPANY
ATTACHING TO AND FORMING PART OF POLICY NO. NPLL67143
NAMED INSURED: Davey Robertsons Public Bar
DBA: The Busted Lift
ENDORSEMENT NO. 1
It is agreed and understood that this endorsement transfers your Liquor Liab~ity
coverage to a secondary location for the dates specified.
Location: Louis Murphy Park
2200 Bunker Hill Rd.
Dubuque, Iowa
52001
Date(s): 10-13-01 to 10-14-01
This endorsement is a part of your policy and takes effect on the date noted above
unless otherwise stipulated.
EFFECTIVE DATE:
10-13-01 to 10-14-01
AUTHORIZED SIGNATURE
THE DECLARATIONS, INSURING AGREEMENTS, DEFINATIONS, EXCLUSIONS,
AND CONDITIONS OF THIS POLICY OTHERWISE REMAIN UNCHANGED.
9/18/2001 kj
TRANSFER
A license or permit may be transferred from one location to another within the boundaries of the approving local
authority. This application is to be used for the transfer of an existing license or permit.
~'PPLIcATION FOR TRANSFER
CHECK LIST
This check list should be used as you complete your Transfer Application. All documents should be properly
signed and correspond with the name of the applicant exactly. All documents must be typed or legibly printed in
black ink. If you have requested a permanent transfer, an amended license/permit will be forwarded to the local
authority. If you have requested a temporary transfer, a letter of permission will be forwarded to the local authority
in lieu of the amended license/permit.
Your application and ali supporting documents should be forwarded to the Iowa Alcoholic Beverages in one
envelope after action of the local authority. Your approved application and all supporting documentation must be
in the Alcoholic Beverages Division's office before the event takes place! Use the following checklist to ensure you
have submitted all required documentation.
Is your Transfer Application typed or printed in black ink?
Have you answered each question on the Application?
Have you signed the Application and had your signature notarized?
If you did not complete your Application, have you and the preparer signed? is
your signature notarized?
[] Have you obtained local authority approval?
Have you included the following documen[s?
Transfers require an endorsement to your dram shop policy. Did you include the required original
endorsement?
Outdoor service areas require an endorsement to your dram shop policy. If you haye an outdoor
service area at your new location, did you include the required original endorsement.
Diagram(s) of a//areas to be licensed.
TRANSFER
TRANSFER APPLICATION
Iowa Department of Commerce
Alcoholic Beverages Division
1918 SE Hulsizer Road
Ankeny, lowa 50021-3948
515-281-7430 · 1-800-831-1393
This Application must be filed with and approved by the Local Authority and the Alcoholic Beverages Division.
The application will not be processed unless all applicable questions are fully answered and all
supportinq documents correspond exactly with the le.qal name of the applicant
I License/Permit # L~..- O0 ~ ~'Z~ I
· TYPE OR PRINT IN BLACK INK ·
il. APPLICANT INFORMATION I
Legat.~_~ Name of _~_ ~~f'~'~ Applicant (Sole Propfietorship,]~ ~)/{ ~_~ Partne?hip, ~ Corporat~on,~.l ~.._. etc.)
Na~,m~e~ of Bus~n~ss-(DBA) - ' ~
Street Address of C~urrent Licensed Premises
Phone Number
City -'T" __
City
TRANSFER DATE t
Temporary~.frorg 24 hours ~rough 7 days)
beginning ~C~'- I'~. '~.(~ I
ending
( ates must fall w~th~n license period,)
Permanent (more than 7 days)
beginning
On Premises Applicants only:
Dram Shop Endorsement Dates: from thru
(Dates must correspond with requested transfer dates. Attach original endorsement. Accord
Certificates not accepted.)
4. NEW PREMISES INFORMATION
The following questions apply to the premises where your license will be transferred:
All Appliqants:
4-1. J~Y [] N Does the premises conform to all local and state health, fire and building laws and
regulations?
4-2. [] Y Are other liquor, wine or beer businesses accessible from the interior of the premises? if yes,
list owner, name and address of other businesses on an attached sheet.
4-3. ~ I Number of bathrooms.
4-4. J Number of floors where alcoholic beverages wil be sold, stored and/or dispensed.
On Premises Applicants Only:
/
4-5. rCJY [] N Is the premises furnished with tables and seats to accommodate a minimum of 25 persons
at one time?
Carry-Out Applicants Only:
4-6. Square footage of retail sales area including area of walk-in coolers which are accessible to
the public. (Class C Beer Permittees only.)
4-7. Square footage of the entire interior area of the building including, but not limited to, all areas
used in the storage, distribution, warehousing, display and wholesale and retail sale of
merchandise and offices, bathrooms, breakrooms, etc. (Class E Liquor Licensees only.)
All Applicants for Permanent Transfers:
4-8. Indicate how you have control of the premises:
.own ~"~-Leas~-~ Other (explain in detail)
If you have indTS'Efb-ET_ease or Other, complete the following:
Landlord ~/~ Tenant
Landlord Mailing ~c~rbs~
Business Phone #
Indicate Leas'~ Dates (include month day and year):
From to
5. INSPECTIONS
Iowa law requires all liquor, wine and beer licensees to give consent to the following individuals to enter areas of the
premises where alcoholic beverages are stored, served, or sold, without a warrant, during business hours to inspect
for violations of the laws and rules governing the license or permit: members of the fire, police, and health
departments and the building inspectors of cities, the county sheriff, deputy sheriffs, members of the department of
public safety, representatives of the division and the department of inspections and appeals, certified police officers,
and any official county health officer.
[] Y [] N As a condition to the issuance of the license, do you agree to grant such consent for the license
period?
2
6. DIAGRAM
Premises Diagram: Draw a clear and understandable sketch of the premises showing all areas under the control or
lease of the applicant. Include all floors where alcoholic beverages are sold, served, consumed and stored.
Indicate alt entrances and exits, location of bar, back bar, bar stools, booths, tables and chairs, bathrooms and where
licenses are displayed. Provide separate diagram for each floor. Diagram(s) does not have to be to scale but must
be 8½ x 11". Use this page for main floor. Attach additional sheets for additional floors. (Blue prints and xerox
copies wlil not be accepted). USE BLACK INK!
Applicant must notify the Alcoholic Beverages Division and the local authority of any changes of boUndaries,
entrances, exits, etc., made after submission of the diagram.
7, OUTDOOR AREA
7-2.
O.tdoorAraaDates: from o~,~¼~ I~ to ~[~ IV:
(Dates must fall within license period.) ~ · .^ ' . , ' ~
(Dates must correspond with requested out~oor se~ice dates. Attach driginal end0rse~ent. Accord
Ce~ificates are not accepted.)
7-3.
Explain how the boundaries of the outdoor area ar,,e designated. (fence, barricades, etc,)
Outdoor Service Diagram: Draw a clear and understandable sketch of the outdoor area showing its
relationship to the licensed premises. __ ack ink.
4
8. SIGNATURES
The Transfer Application must be signed by the applicant and the preparer if the Application is not completed by
the applicant. Stamped signatures are not acceptable.
Who must sign as applicant:
Sole Proprietorship - Individual; General Partnership - Partner; Limited Partnership - General Partner; Limited
Liability Partnership - Genera] Partner; Privately-held Corporation - Officer; Publicly-traded Corporation - Officer;
Limited Liability Company - Officer or Manager;. Non-profit Association - Principal
APPLICANT
I hereby declare that all information contained in the Transfer Application is true and correct. I further declare that I
have completed the Ai~ication en~elf, unless it is also signed by a Preparer.
/11'~
ture ~ ~/~ate /
Nota~
State of
County of
Signed and sworn to before me on
Date
by
Pdnt Name of Applicant
Signature of Notary
My commission expires:
PREPARER
I declare that I have examined this TransferApplication and to the best of my knowledge and belief, ali information is
true, correct and complete. I further declare that I have reviewed the information contained in the Application with
the applicant.
Preparer's Signature
Title
Date
This document is an open record. Information contained in this document may be disclosed without prior notice to or
permission from the subject. See Iowa Code chapters 22 and 123; see, also, 185 Iowa Administrative Code, ch. 18.
9. ENDORSEMENT OF LOCAL AUTHORITY 1
I hereby certify that the Transfer Application was submitted to:
on
City Council or County Board of Supervisors
It is recommended that the Transfer be: [] Approved
it is further recommended that the Outdoor Service Area (if applicable) be:
Date
Denied
[] Approved
[] Denied
Name of City or County
Street Address or P.O. Box #
Contact Person
Daytime Phone #
Signature of City or County Official