299 Atlantic Boulevard DOGS21-0001 (MShack)A
IN
RESTAURANT PERMIT APPLICATION (Per ordinance No,95-10-1-02)
nOG-FRIENDLY 1
City of Atlantic Beach
Department
Community Development
800 Seminole Road Atlantic Beach, FL 32233
(P) 904-247-5800
FOOD SERVICE ESTABLISHMENT INFORMATION: FL DHR #
FAME OF ESTABLISHMENT M SHACK AB sTR #
ROPERTY ADDRESS 299 Atlantic Blvd. PHONE #
;rrY STATE, ZIP Atlantic Beach, Florida 32233 FAX #
-WAIL ADDRESS
Submittal
Z. APPLICANT INFORMATION: Requirements
NAME OF APPLICANT M SHACK
COMPANY MSAB LLC Application Fee: $175
MAILING ADDRESS 2107 Hendricks Ave Completed Permit ry
CITY, STATE, ZIP Jacksonville, FI 32210 Application Fortn
EMAIL ADDRESS dalvin.devine@mhospitalityfl.com proof of Ownership �✓
FAX #
PHONE # 904-241-2599
Authorized Agent
IF DIFFERENT FROM APPLICANTE
Affidavits (if applicable)
3. PROPERTY OWNER INFORMATION,
NAME OF OWNER SOUTHCOAST CAPITAL PTNRSHP LTD
Proof of Insurance
COMPANY SOUTHCOAST CAPITAL PTNRSHP LTD Diagram of Designated
Outdoor Dining Area
MAILING ADDRESS 1 Independent Dr. #1600
CITY, STATE, ZIP Jacksonville, Florida 32202 General Regulations Form
EMAIL ADDRESS FAX #
PHONE # 904-634-8808
6. DAYS & HOURS
4. PROOF OF OWNERSHIP: DOGS ALLOWED:
' - I
Please check the box of the applicable document and attach a copy to this ortn. �
DUVAL COUNTY PROPERTY RECORD CARD r DWAL COUNTY RECORDED DEED �`vSUN i ( ._•. _ � �'�
r- (-t/MON
rrvE
5. PROOF OF INSURANCE: copy f our certificate providing
per
�'/ WED
Please provide anroti gin li certificate
rnsurae o insurce in ance,
or h of ftverh undred thousand dollars ($500,000.00) c
commercial gene Jfor rVj rHU jf <�% .z
occurrence and one millodollars ($11000`Oon'OOs aggregate, uly rized to do business of the State l f Fl ridas
animal bites. All insurancef� i
Thirty (30) days written notice must be given to the City of Atlantic Beach Risk Managetnettt prior to any FRI e.
erage. The City of Atlantic Beach Risk Management (800 Seminole
cancellation or reduction in policy cov
Road, Atlantic Beach, FL 32233) must
be listed as a certificate holder. AND UNDER PENA
AD THE INFORMATION IN THIS APPLICATION CATION ARE TRUE
I HAVE RELTIES OF
PERJURY, I DECLARE THAT THE FACTS STATED IN THIS APPL
�� nnr,-FRIENDLY RESTA URA NT PERMIT APP 02.13.2019
PLICANT'S PRINTED NAME
54
Pill
Bids POP SIMON Million iiiiiiiiiiiiiii Slow III I III
III
III
low
DOG-FRIEN
c DLY REIII STIII AUIII R 1111 A 1111 NIN T PERMIT APPLICATION (Per Ordinance No. 95-10-102)
City of Atlantic Beach
t Department
Conimunity Developmen
800 Seminole Road Atlantic Beach, FL 32233
(P) 904-247-5800
AUTHORIZED AGENT AFFIDAVIT
NAME OF ESABLLSHMENT MI.
Shack Atlantic Beach
is hereby authorized to ACT ON BEHALF OF
or,the owner(s) of those lands des
rrwoLrl�cribed within
the attached application, and as described
•
be required by the of n
By.,rnmVllU
in the attached deed or other
RESTAURANT PERMIT.
such proof of ownership as may
for a DOGFRIENDLY
Signed and sworn before me on this
Identification verified:
l-�
O
STATE OF F
COUNTY a t� V
Oath sworn:
My Commission exp>res:
.., „n�_cRrFnlnl Y RESTAURANT PERM►TAPP 02.13.2019
Yes
ASHLEY ANN
HOLMES
MY COMMISSION # GG 359046
EXPIRES: October 8, 2023
Bonded Thru Notary Public Underwrite
DLY RESTAURANT PERMIT
City of Atlantic BmenhDepacartment
Community Develop
0 Seminole Road Atlantic Beach, FL 32233
AP
D®O-FRIEN
PLICATION (Per Ordinance No. 951u-luz)
80
(P) 904-247-5800 ENFORCEMENT AND PENALTY
GENERAL REGULATIONS, COOPERATION,
each item acknowledg�►g that you have read and understand the terms.
Initial next to e FL DHR # _
I l/'T ,Lt/1 �l
NAME OFTABLiSHMENT (� I
attended for any period
9, The applicant agrees and confirms that patrons shall be instru their dogsu unattended
dogs on a leash and
or rabies tag and the patron shall have a current
under reasonable control at all times. Patrons shall not leave 3 Q_b
of time. All dogs shall wear a current license tag
license or rabies certificate immediately available upon request. [Section 24 158(e)(2J: �() ]
to ees and patrons shall be instructed that ougd level
10. The applicant agrees and confirms that eshall
mp Y s must remain on the floor/gr
of the patrons [Section 24-158(f)(2)e: O(3)d]
not be allowed on chairs, tables, or other furnishings. Dogs
and shall not be permitted in the lap
spilled food and drink shall be removed as
agrees and confirms that all able and chair
surfaces shall be cleaned and sanitized
11. The applicant g of atrons. p
}� with an approved product between seating P patrons at the nearest table.
\ soon as possible, but in no event less frequently than between seating of
[Section 24458(f)(2)f 91
and patrons shall be instructed that accidents d
cts
12. The applicant agrees and confirms that employeesr oved p
involving dog waste shall be cleaned innmediaose shall be kept in thy and the area e designated outdoor areas Dog
h any indoor portions of the public food service
_ A lrit with appropriate materials for this purpose
waste shall not be carried in 4 �(2)h, (f)(3)e]
establishment. [Section 24 158(e)( ), art shall not be transferred
permit issued pursuant to this p
13. The applicant agrees and confirms that a p ublic food service establishment, but shall
to a subsequent owner upon the sale or transfer of a p
automatically upon such sale or transfer. The subsequent owner shall be required to reapply
expire art if such owner wishes to continue to accommodate patrons' dogs.
for a permit pursuant to this p
[Section 24458(d)(3)h]
Division of Hotels and Restaurants of the
The applicant agrees and confirms that in accordance with section 509.233(5), Florida Statutes, e
` 14. T pp of all approved applications
,( Community Development Director shall provide the
Florida Dep Development Director shall accept and
_ artment of Business and Professional Regulation with a copy
pursuant to this part. Further, tFriendl Restaurant Program within the City, and shall
issued p y
document complaints related to the Dog
mel report to the Division of Hotels and Restaurants, all such complaints and City's enforcemen
to Y
response to such complaint. [Section 24458(8)
agrees and confirms that failure to comply with the requirements of this pre -
15. The applicant aur general
application consultation shall be a violation of the
the° pplicablelprovisi ns of the Code and ll be tg o an
proceedings consistent w
and all enforcement
law. [Section 244SB(d)(6)]
-Friendl Restaurant Program. I understand it is
co of Section 24-158 of the Atlantic Beach Municipal Code of Ordinances and that I have
said
I verify that I have received a Iro proposed application for participation in the g
counseled by staff regarding my p p patrons comply with all regulations at all times, and that failure to comply with
my responsibility to ensure all employees and p
esult in the revocation of my Dog -Friendly Restau
regulations may rrant Permit.
_ ��--- 7)A , , r -r, ii ATE
.r ennm 1� 7IJ7Y
26DOG-FRIENDLY RESTAUHH�� � r�n,v,,, . ••
Page 2 of 2
Ci o f Affan& Beach
DOG FRIENDLY RESTAURANT PERMIT APPLICATION
(Per Ordinance No. 95-10-102)
DIAGRAM OF DESIGNATED DOG -FRIENDLY OUTDOOR SEATING AREA
In the space below, provide a diagram (to scale) of the designated outdoor seating area showing the following:
• Boundaries of the designated dog friendly outdoor seating area with dimensions, to scale
• Boundaries of any non -designated outdoor seating area with dimensions, to scale
• Number and placement of tables, chairs and restaurant equipment
• Location of entrinvaus to and exits from all designated and nondesignated out
Wrens
• Location of all fences and/or barriers
• way, including sidewalks, curbs, common pathways and public improvements,
Location of property lines and public rights -of -
such as benches, fire hydrants, etc J
NAME OF ESTABLISHMENT
Inspected £� Approved Inj:
DOG_v2011.01
a:
u�
w
_a
U
O
� �
d Q
s �iS
a �
Q �
� �
O � � �
U
Q M N V"
� o � �
v °� o d U
c
m C � � LLL1.
_ � rn H O
O U � ��
N � � �I �
r
N
O
N
Of
r
d op rn
� � z~ � p Q N N
v
W M j N W N �� N
� �j NI W Q J d J W O O
v (�
F- LLI o H '= Y L1J p Y W
� Z L ` � U � j _U � �
Y � � � � D � � � � � �'
� Q D > co
� (' ►� � W W O � W W O � �
�f (� tC C7 �
�� `�s�, E m � h Y � p ti Y � a ao rn
W o U W o U c m� .-
oo� a z � �N� �N� 4 oC N N
M
N
a
m
rn
N
O
W
O
O
O
O
r
T
J
z
0
a
0
a
0
U
LL
Z
_N
7
0
e
w
z
W
a
.�
0
.-
N
Q
N
.-
1
��
0
c
a�
�.
rwi'
#+
W
r��
a
O
U
.�'
ca
J
J
t�
a
.�
0
J
J
Q
-.
4�
N
O
O
O
O
r
J
i
d
s�
a
C
m
7
v
0
0
N r r
O `� �
ti N N
d' O O
d
Z
W
4J
J
'��
W
H
Q
W
N
J
m
U
Z
J
Q
rn
rn
N
f+'3
M
N
ch
J
LL
Q
W
m
F-
Q
��
N
0
N
O
M
O
m
c
c�
U
N
'a
d
.�
m
a
m
M
N
O
O
O
O
O
Y
r_
J
Agenty Code 12-0657-00
NAMED INSURED SCHEDULE
CWF INC
DBA MATNEW'S RESTAURANT
C/O MATHEW MEDURE
D&M ASSOCIATES, LLC
ENTITY: LIMITED LIABILITY
COMPANY
HIPP, LLC
DBA: HIPP FITT
ENTITY: LIMITED LIABILITY
COMPANY
M HOSPITALITY LOGISTICS
LLC
ENTITY; LIMITED LIABILITY
COMPANY
M SHACK HOLDINGS, LLC
ENTITY:
LIMITED LIABILITY
COMPANY
.--~vMSA6, LLC _-, __._ __.-��___�
DBA: M SHACK
ENTITY: LIMITED LIABILITY
COMPANY
5N ,LLC ,-_.--_---
_
DBA: M SHACK
ENTITY: LIMITED LIABILITY
COMPANY
MSTC, LLC
DBA: M SHACK
ENTITY: LIMITED LIABILITY
COMPANY
ROUX OF PONTE VEDRA INC
DBA: RESTAURANT MEDURE
ENTITY: CORPORATION
RUE 2103 LLC
DBA: RUE SAINT MARC
ENTITY: LIMITED LIABILITY
COMPANY
SOBU, LLC
DBA: MIDTOWN TABLE
ENTITY:
LIMITED LIABILITY
COMPANY
59270 (2-97)
Policy Number 204622-78407133
59270 {2-97)
Page 1 of 1
Southern -Owners Ins. Co.
AGENCY WELLHOUSE COMPANY LLC
12-0657-00 MKT TERR 123
INSURED CWF INC
Page 3
Issued 0446=2020
Company POLICY NUMBER 2046224840713340
Bill 7846 -FL -2003
PROPERTY PLUS COVERAGE PACKAGE DECLARATION
COVERAGE
Term 03-26-2020 to 03-26-2021
LIMIT
55198
$2,500 PER ITEM
BAILEES $59000
$4500 PER ITEM
EMPLOYEE DISHONESTY $150000
FORGERY AND ALTERATION $100000
MONEY AND SECURITIES INSIDE PREMISES $150000
MONEY AND SECURITIES OUTSIDE PREMISES $159000
FIRE DEPARTMENT SERVICE CHARGE $5,000
Forms that apply to this coverage part:
54182 (06-00) 54205 (0
54188
(06-00)
54199
(06-00}
1-07)
(06-00)
54190
(01-07)
(06-00)
54223
(06-00)
54208
(06-00)
54191
(06-00)
54196
(06-00)
54192
54189
(08-10)
54183
54207
(06-00)
54186
54217
(06-00)
54218
54220
(06-00)
54216
54219
(06-00)
54214
54188
(06-00)
54199
(06-00}
54198
(06-00)
54184
(06-00)
54185
(06-00)
64281
(06-17)
54195
(06-00)
54197
(06-00)
54192
(06-00)
54183
(06-00)
54186
(06-00)
54218
(06-00)
54216
(06-00)
54214
(06-00)
54221
(06-00)
54193
(06-00)
54338
(01-07)
54339
(01-07)
SOME OR ALL OF THE LOCATIONS ON THIS POLICY CONTAIN
AN EXCLUSION FOR THE PERILS OF WINDSTORM AND HAIL,
Coverages Provided
Insurance at the described premises applies only for coverages for whit► a Knit of insurance is shown.
HURRICANE DEDUCTIBLE
IN AK
lY ONE OCCURRENCE OF A HURRICANE, THE TOTAL
DEDUCTIBLE FOR ALL COVERED HURRICANE LOSSES
WILL BE A MINIMUM OF $1,000. PLEASE SEE ATTACHED
FORM FOR ADDITIONAL DEDUCTIBLE INFORMATION.
THIS POLICY CONTAINS A CO -PAY PROVISION THAT MAY
RESULT IN HIGH OUT-OF-POCKET EXPENSES TO YOU.
(LOCATION 0001 - BUILDING 0001
Location: 2107 Hendricks Ave, Jacksonville, FL 32207-3370
Occupied As: Restaurant
Southem-Owners Ins, Co,
AGENCY WELLHOUSE COMPANY LLC
12-0657-00 MKT TERR 123
INSURED CWF INC
Page 2
Issued 04-16-2020
Company POLICY NUMBER 204622-78407133-20
Bill 78-46 FL -2003
COMMERCIAL PROPERTY COVERAGE
Term 03-26-2020 to 03-26-2021
54104 (12-1
--- 55198 (01-07)
PROPERTY PLUS COVERAGE PACKAGE DECLARATION
The coverages and limits below apply separately to each location or sublocation that sustains a loss to covered property and is
designated in the Commercial Property Coverage Declarations. No deductible applies to the below Property Plus Coverages.
COVERAGE — ----_— �._ LIMIT
ARSON REWARD $7,500
BUSINESS INCOME & EXTRA EXPENSE WIRENTAL $500000
VALUE, INCLUDING NEWLY ACQUIRED LOC'S
BUSINESS PERSONAL PROPERTY - AT FAIRS OR EXHIBITIONS $5,000
BUSINESS PERSONAL PROPERTY - EXPANDED COVERAGE UP TO 1,000 FEET
DEBRIS REMOVAL $250000
FIRE EXTINGUISHER AND FIRE SUPPRESSION SYSTEM RECHARGE $1 Q000
GLASS BREAKAGE WITHIN BLDG OR BUSINESS
PERSONAL PROPERTY LIMIT
INVENTORY UP TO 25% OF BPP LIMIT
NEWLY ACQUIRED OR CONSTRUCTED PROPERTY $1,000,000 FOR 90 DAYS
NEWLY ACQUIRED BUSINESS PERSONAL PROPERTY $500,000 FOR 90 DAYS
OFF -PREMISES UTILITY SERVICE FAILURE $50,000
BUSINESS INCOME/EXTRA EXPENSE
($10,000 SUBLIMIT)
ORDINANCE OR LAW $500000
OUTDOOR PROPERTY $100000
TREES, SHRUBS OR PLANTS $1,000 PER ITEM
PERSONAL EFFECTS AND PROPERTY OF OTHERS $150000
POLLUTANT CLEAN UP AND REMOVAL $251000
PROPERTY IN TRANSIT $25,000
PROPERTY OFF PREMISES $25,000
REFRIGERATED PRODUCTS $102000
REKEYING OF LOCKS $10000
WATER BACK-UP FROM SEWERS OR DRAINS $150000
ACCOUNTS RECEIVABLE $100,000
SIGNS (ATTACHED AND DETACHED) $50000
ELECTRONIC DATA PROCESSING EQUIPMENT $25,000
SALESPERSON'S SAMPLES $10,000
VALUABLE PAPERS $500000
FINE ARTS, COLLECTIBLES AND MEMORABILIA $106000
efouthern-Owners Page 1
Issued 0416-2020
INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AGENCY WELLHOUSE COMPANY LLC New Business Effective 03-26-2020
12-0657-00 MKT TERR 123 904-256-9481 POLICY NUMBER 20462248407133-20
INSURED CWF INC Company Use 7846 -FL -2003
SEE FORM 59270
Company Policy Term j
ADDRESS 2107 HENDRICKS AVE Bill ! 12:01 a.m. 12:01 a.m.
JACKSONVILLE FL 32207-3370 03-26-2020 to 032&2201
THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR
HURRICANE LOSSES, WHICH MAY RESULT IN HIGH
OUT-OF-POCKET EXPENSES TO YOU.
55039 (11-87)
COMMON POUCY *11FDRMATION
Business Description: Restaurant Group
Entity: Corporation
Program: Restaurant Service
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S):
COMMERCIAL. PROPERTY COVERAGE
COMMERCIAL GENERAL LIABILITY COVERAGE
LIQUOR LIABILITY COVERAGE (REFER TO COVERAGE PART)
SURTAX
FLORIDA EMERGENCY TRUST FUND SURCHARGE
TOTAL
PAID IN FULL DISCOUNT
TOTAL POLICY PREMIUM IF PAID IN FULL
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
The Paid in Fult Discount does not apply to fixed fees, statutory charges or mininum premiums.
PREMIUM
$30,636.00
$30,201.00
(INCLUDED)
$60.76
$4.00
$60.907.76
$6.084.08
$54,817.68
1111U111 arwwn aDVve Tor commercral general IiabiNty coverage is an advanced premium deposit and may be subject to audit.
Forms that apply to all coverage part(sj shown above (except garage �ab�ity. dealer's blanket, commercial automobile, if appticab�):
IL0017 (11-$5) 55156 (07-12)
A 08% Cumulative Mufti -Policy Discount applies, Supporting poises are marked with an (X):
Comm Umb(X) Comm Auto(X) WC() Life() Personal() Farm(.
Countersigned By: WELLHOUSE COMPANY LLC