Restaurant/Tavern Supplement

Personal Information
First Name Required Input Required
Last Name Required Input Required
Street Required Input Required
City Required Input Required
State Required Input Required	select AL AK AZ AR CA CO CT DE FL GA HI ID IA IL IN KS KY LA ME MD MA MI MN MS MO MT NC ND NE NV NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Type of Business Required Undefined
General Information
Is any entertainment provided? Required Undefined	select Yes No
Nights of Week Optional	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Type of Clientele Optional
Type of Entertainment Optional	Rock Group DJ Band (Any Kind) Other (Desribe)
If Other, please describe here Optional
Does a Dance Floor exist? Optional	Yes No
Is Dancing Permitted? Optional	Yes No
Bouncers or Doorment? If yes, explain why. Optional
Amusement Devices (Pool Tables, Video Games, Gambling, etc)? If yes, # and description. Optional
Seating Capacity Required Undefined
Seasonal? Required Undefined	select Yes No
Any Grilling, Deep Fat Frying, Open Broiling, or Roasting? Required Undefined	select Yes No
Has Business been in operation less than 5 years at this location? If yes, describe prior experience of Owner/Manager. Required Undefined
Number of Employees
Full-Time Required Undefined
Part-Time Required Undefined

Kitchen Fire Protection
U.L. 300 Approved Automatic Extinguishing System Under Maintenance Contract? If yes, # months.. Required Undefined
Does above system cover all cooking surfaces? If yes, name system. Required Undefined
Automatic Gas, or Electric shut offs for cooking? Required Undefined	select Yes No
BC and K extinguishers available in kitchen? Required Undefined	select Yes No
Hood and Filters cleaned weekly by staff? Required Undefined	select Yes No
Hoods and ducts mainenance contract schedule? Required Undefined	select Yes No
# Months: Required Undefined
Adequate clearance between hoods, ducts, cooking equipment, and combustible materials? Required Undefined	select Yes No
General Liability
Reciepts (Last 3 Years) Required Undefined	select Yes No
Food
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Liquor
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Other
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Year and Total $ Required Undefined
Square Footage
Total Building Required Undefined
Restaurant Required Undefined
Apartments Required Undefined
# Apartments Required Undefined
On or Off Permises Catering/Banquet Required Undefined	select Yes No
If yes: % of total receipts Optional
Describe Catering Operation Required Undefined
Non-Owned Automobile? Required Undefined	select Yes No
If yes, # of Employees Optional
Valet Parking? Required Undefined	select Yes No
If yes, is Garage Keepers Liability Required? Optional	Yes No
Any Deliveries? Required Undefined	select Yes No
If yes, describe Optional
Liquor Liability
Does Applicant Serve Alchohol? Required Undefined	select Yes No
Does Applicant Have Liquor License? Required Undefined	select Yes No
If yes, type and #: Optional
# of Bartenders? Required Undefined
# of Waiters/Waitresses Required Undefined
Avg length of employment Required Undefined
Are Employees Given Liquor Training? Required Are Employees Given Liquor Training? is required.	select Yes No
If Yes, Explain Type and When Trained Optional
Does Applicant Have Written Policy on Serving Alcohol for Employees and Customers? Required Does Applicant Have Written Policy on Serving Alcohol for Employees and Customers? is required.	select Yes No
Is Management Notified Prior to Shutting Off Patrons? Required Is Management Notified Prior to Shutting Off Patrons? is required.	select Yes No
Is Documentation Kept on Each Incident? Required Is Documentation Kept on Each Incident? is required.	select Yes No
# Of Bars On Premises Required # Of Bars On Premises is required.
Is There A Happy Hour? Required Is There A Happy Hour? is required.	select Yes No
Is A Last Call Given? Required Is A Last Call Given? is required.	select Yes No
Have There Been Any Liquor Board Violations? Required Have There Been Any Liquor Board Violations? is required.	select Yes No
If Yes, List All Violations Optional
Enter Validation Code Required

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