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363 Atlantic Boulevard DOG Dining 09.24.2012 (Poe's) /e2-4/oe,3.3 IOW ,•� eitli of.Atlantic �eacIi DOG FRIENDLY RESTAURANT PERMIT APPLICATION (Per Ordinance No.95-10-102) 1. FOOD SERVICE ESTABLISHMENT INFORMATION: NAME OF ESTABLISHMENT Poe's Tavern FL DHR# SEA-2612482 PROPERTY ADDRESS 363-1 Atlantic Blvd#1 AB BTR # BTR-12-00007435 CITY,STATE,ZIP Atlantic Beach,FL 32233 PHONE# (904)241-7637 EMAIL ADDRESS eevaul14@gmail.com FAX # 1.1 A. 2. APPLICANT INFORMATION: - NAME OF APPLICANT Riddick Lynch/Eric Evaul . Submittal Requirements COMPANY Poe's Tavern MAILING ADDRESS 363-1 Atlantic Beach Renewal Fee:$125.00 IX CITY,STATE,ZIP Atlantic Beach,FL 32233 Completed Permit EMAIL ADDRESS eevaul14@gmail.com Application r lication Form X PHONE# (904)241-7637 FAX # Proof of Ownership r 3. PROPERTY OWNER INFORMATION,IF DIFFERENT FROM APPLICANT: Authorized Agent r Affidavits(if applicable) NAME OF OWNER Chris Hionides,Managing Member COMPANY Shoppes of Norshore LLC roof of InsuranD MAILING ADDRESS 2440 Mayport Road,#7 Diagram of Designated Outdoor Dining Area CITY,STATE,ZIP Atlantic Beach,FL 32233 ( Completed Pre-Application EMAIL ADDRESS ��,0,1c,(e � f -k,re- py,eto t�eti - Consultation Form PHONE# e10 . 1.(i 157 FAX # n/A 4. PROOF OF OWNERSHIP: 6. DAYS &HOURS Please check the box of the applicable document and attach a copy to this form. DOGS ALLOWED: F.< DUVAL COUNTY PROPERTY RECORD CARD fl DUVAL COUNTY RECORDED DEED r SUN 11 am-2am 5. PROOF OF INSURANCE: r MON 11 am 2am Please provide an original certificate of insurance,or have your agent fax a copy of your certificate providing IX TUE 11 am-2am commercial general liability insurance in the amount of five hundred thousand dollars ($500,000.00) per r WED 11 am-2am 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. Ix THU 11am-2am Thirty(30)days written notice must be given to the City of Atlantic Beach Risk Management prior to any r FRI 11am-2am 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. rX SAT 11 am-2am I HAVE READ THE INFORMATION IN THIS APPLICATION AND UNDER PENALTIES OF PERJURY, I DECLARE THAT THE FACTS STATED IN THIS APPLICATION ARE TRUE. APPLIC 4NTS SIGNATURE APPLICANT'S PRINTED NAME DATE DOG_v2011.01 • "'L� ICity of 4t{antie Veaeli `'s Ailko DOG FRIENDLY RESTAURANT PERMIT APPLICATION j ' � (Per Ordinance No.95-10-102) #fir I`). 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 ESTABLISHMENT Poe's Tavern FL DHR# SEA-2612482 MI rail;; , � ' eea — --- I ii ( . _ .,.N r.1 j) 71 fyl 0 \ .. ' , II ,_t •li 0-.. 1. MI . i i.. ^ ' ,'.-- '._fit I r-i • n SOOOMMIS. ( '.. � wx. i • 1: ,O ■ OMB'M•■ a ■ it 1 r it r t; ti•.• • w . -------a..,...—...--, II 1 r• ■ r',#:.:_,.---- --.......... � r j � w y Y F 07 n.____. . p....._ , .... . „.. .„ ; '. . .. '• -Z..: '. '; ) Ilk a 0 a ifil Fri ,.+'+ fes' i _ 3 I ' \ Inspected&Approved by: 0 '00/ APPLICATION 1ST QTR 2ND QTR 3RD QTR 4TH QTR APPROVAL INSPECTION INSPECTION INSPECTION INSPECTION DOG v2011.01 "... OP ID: PW ACC) 09/26 ?L CERTIFICATE OF LIABILITY INSURANCE DATDlYYYYI 09/26112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). . PRODUCER Phone: 843-881-2229 coNrA' cr McKay,Stelling&Associates Ro - `���- FAx P.O.Box 688 Fax: 843-881-2459 (AIC,No,Ext):.........._....... . ......._....._...__.................._........._...............ta?.c,No):_........._.........._............. Mt.Pleasant„SC 29465 E-MAIL Kathy D. McKay -PRODUCER................ CUSTOMER ID a POEST-1 ........ ......................... ._......... ... INSURER(S)AFFORDING COVERAGE NAI:M INSURED Poe's Tavern-Jax Beach LLC INSURER A:Travelers Insurance 363 Atlantic Blvd ......................................................_..._......_ Atlantic Beach, FL 32233 INSURER 13 Hartford Insurance Company INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR .. ---._..__....... ....._...._..._..._. ADDL SUBR ........___... ........._....._._..............._.............-POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD, POLICY NUMBER (MMIODIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY X 6208W7157 08/01/12 08/01/13 'PREMISES fEeoccurrence), $ 100,000 CLAIMS-MADE I X j OCCUR MED EXP(Any one person) $ 5,000 PERSONAL S ADV INJURY I$ 1,000,000 X Non Owned and Hir GENERAL AGGREGATE $ 2,000,000 GEN'/AGGREGATE LIMIT APPLIES PER: i PRODUCTS-COMP/OP AGG $ 1,000,000 ....-, c--- �...-. I__ _.. ... .. fGRO- I j X I POLICY 1 I JEcr I 1 LOC LiquorLia i , 1,000,000 AUTOMOBILE LIABILITY ? ; COMBINED SINGLE LIMIT 1 $ ... ' I (Ea accident) f ....., ANY AU'EQ � i I I � BODILY INJURY(I or person) t$ Al.l.OWNED AUTOS t t �__..........................._...__....... •- - BODILY INJURY(Per accident)!$ SCHEDULED AUTOS � -� PROPERTY DAMAGE A X HIRED AUTOS i ! I(Por accident) $ 111 _..._... _.................. . ..........._...................... ... A X NON-OWNED AUTOSINCLUDED IN GL $ $ UMBRELLA LIAB X OCCUR j } EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CLAIMS-MADE I AGGREGATE $ 2,000 000 A —..-__-- _ ._ _._...._._..__- .I 620W7157 08/01/12 08/01/13 DEDUCTIBLE I $ X RETENTION $ 5000 ( $ WORKERS COMPENSATION IWC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ..X..L79RY LIMOS _.....__..j_S7.i...................._........_.....___._-.. B ANYPROPRIETOR/PARTNERIEXECUTIVE22WECG3641 08/01/12 08/01/13 E.L.EACH ACCIDENT $ .500,000 OFFICER/MEMBER EXCLUDED? Li N/A (Mandatory In NH) E.L. ISEASE EA EMPLOYEE $ 500,000 {If yes.describe under .-... __. ........ __.. _.......... .. DESCRIPTION OF OPERATIONS below � E.L.DISEASE-POLICY LIMIT $ 500,000 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schodulo,If moro space Is required) Family Style Restaurant with liquor sales. The certificate holder is an additional insured, landlord. CERTIFICATE HOLDER CANCELLATION PETRAMA SHOUL ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Petra Management Inc. THE I XPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 ACCO DANCE WITH THE POLICY PROVISIONS. Bethany Salcan P.O. Box 330448 AUTHOftIFED REPRE ENT'TIVE ? n Atlantic Beach, FL 32233-0448 i Katkiy;D. M y ©4988-2 09 A ORD CORPORATION/. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of AC(3 D ;51..A.N is City of Atlantic Beach'(-- APPLICATION NUMBER --A Building Department (To be assigned by the Building Department) 800 Seminole Road '`°W--'-' Atlantic Beach, Florida 32233-5445 ./ 2 —/D O O 5J \ Phone(904)247-5826 • Fax(904)247-5845 , r E-mail: buildin de t coab.us Date routed: w - z- 'z City web-site: http://www.coab.us APPLICATION REVIEW AND TRACKING FORM Property Address: 3 3 - I L Department review required Yes No Building Applicant: ?Cl-e--- (G '�-'t"- -� Planning&Zoning ✓ Tree Administrator Project: TiDO- ��C,GU`"�- Public Works cJ J Public Utilities Public Safety _ Fire Services Review fee $ li,5•0° efL Dept Signature at Other Agency Review or Permit Required Review or Receipt Date of Permit Verified By Florida Dept. of Environmental Protection Florida Dept. of Transportation St.Johns River Water Management District Army Corps of Engineers Division of Hotels and Restaurants Division of Alcoholic Beverages and Tobacco Other: APP ICATION STATUS Reviewing Department First Review: 24Approved. ❑Denied. (Circle one.) Comments: BUILDING &ZONING Reviewed by: g141- PLANNING aet.fIC Date: (O ihZ__ TREE ADMIN. Second Ravi, PUBLIC WORKS Comments: PUBLIC UTILITIES -.F 7 3$ 2 821 A PUBLIC SAFETY , i hflithd @ ite: ro ¢ wuw. Y. ... FIRE SERVICES Third Review *▪ A •• .. 0 Comments: a 8 s c si CCF— . G.33 N N �p ya yj rho QZ� 4..•g a gib <u -, m ite: .-. — 11 4... * c .44 1 12 lu 6'"41§i 00 * \ •.moi N W Y C ,••• 4. Revised 07127110 m --4,z, a. a id u Yom a OG A IL o o i I- F-1- F.