CE DD 30 Ocean Blvd 2012 r ,
M `
-=rAl r„, Ci of Atlantic beach
as DOG FRIENDLY RESTAURANT PERMIT APPLICATION
(Per Ordinance No 95-10-102)
1. FOOD SERVICE ESTABLISHMENT INFORMATION:
NAME OF ESTABLISHMENTJOSeph's Pizza FL DHR# SEA-2613508
PROPERTY ADDRESS 30 Ocean Blvd AB BTR # BTR 12 00006118
CITY,STATE,ZIP Atlantic Beach,FL 32233 PHONE# (904)270-1122
EMAIL ADDRESS FAX # (904)270-1 189
2. APPLICANT INFORMATION:
Submittal
NAME OF APPLICANT Sandra Hanania
COMPANY Joseph's Pizza Requirements
MAILING ADDRESS 30 Ocean Blvd Renewal Fee:$125.00 r
CITY,STATE,ZIP Atlantic Beach,FL 32233 Completed Permit
IR
EMAIL ADDRESS sbhJoseph @comcast.net Application Form
PHONE# (904)270-1122 FAX # (904)270-1189 Proof of Ownership r
3. PROPERTY OWNER INFORMATION,IF DIFFERENT FROM APPLICANT: Authorized Agent r
Affidavits Of applicable)
NAME OF OWNER tunny Jubran
roof of Insurance R.
COMPANY Jubrana Jubran et al
MAILING ADDRESS 9912 Vineyard Lake Lane Diagram of Designated r.
Outdoor Dining Area
CITY,STATE,ZIP Jacksonville,FL 32256
EMAIL ADDRESS Completed Pre-Application r
Consultation Form
PHONE# FAX #
4. PROOF OF OWNERSHIP: 6. DAYS &HOURS
Please check the box of the applicable document and attach a copy to this form. DOGS ALLOWED:
r DUVAL COUNTY PROPERTY RECORD CARD r DUVAL COUNTY RECORDED DEED (X SUN loam-10pm
r MON 1closed
5. PROOF OF INSURANCE:
r TUE 11 am-10pm
Please provide an original certificate of insurance,or have your agent fax a copy of your certificate providing
commercial general liability insurance in the amount of five hundred thousand dollars ($500,000.00) per E WED 11 am-10pm
occurrence and one million dollars ($1,000,000.00) aggregate. The policy shall not have exclusions for
animal bites. All insurance shall be from companies duly authorized to do business in the State of Florida. r THU 11am-10pm
Thirty(30)days written notice must be given to the City of Atlantic Beach Risk Management prior to any FRI 1 1 am-11pm
cancellation or reduction in policy coverage. The City of Atlantic Beach Risk Management (800 Seminole
Road,Atlantic Beach, FL 32233)must be listed as a certificate holder. r SAT loam-11pm
I HAVE READ THE INFORMATION IN THIS APPLICATION AND UNDER PENALTIES OF
PERJURY, I DECLARE THAT THE FACTS STATED IN THIS APPLICATION ARE TRUE.
APPLICANT'S SIGNATURE APPLICANT'S PRINTED NAME DATE
DOG_v2011.01
,I, ,?x,r,� Ci of Atlantic Beach
. DOG FRIENDLY RESTAURANT PERMIT APPLICATION
-5 (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 entryways to and exits from all designated and non-designated outdoor areas
• Location of all fences and/or barriers
• Location of property lines and public rights-of-way,including sidewalks,curbs,common pathways and public improvements,
such as benches,fire hydrants,etc
NAME OF ESTABLISHMENTJ05eph's Pizza F.DI IR# SEA-2613508
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