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Colony Restaurant Supplemental Application
Restaurant/Tavern/Bar/Nightclub PDQ General Liability Supplemental Application
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Email
*
Your email
Applicant Name
Your answer
Date
MM
/
DD
/
YYYY
Location address
Street, City, State, Zip
Your answer
Applicant's Website Address
Your answer
Agency Name
Your answer
General Information
Receipts
In dollars
Your answer
Food
In dollars
Your answer
Liquor
In dollars
Your answer
Cover
In dollars
Your answer
Other
In dollars
Your answer
Total
In dollars
Your answer
Seating Capacity
Your answer
Operating Hours
Your answer
Square Footage of Building
Your answer
Years in business at this location
Your answer
APPLICANT INFORMATION
Are the owners active in the business?
Yes
No
Clear selection
Number of Years Experience
Your answer
Is the applicant a tenant or do they own the building?
Yes
No
Clear selection
Are there any apartments in the building?
Yes
No
Clear selection
If so, how many?
Your answer
Has the applicant filed Bankruptcy (Chapter 7, 11 or 13) or is the applicant in receivership (prohibited)
Yes
No
Clear selection
Has the applicant's insurance been cancelled or non-renewed in the past year?
Option 1
Clear selection
If yes, provide details
Your answer
Check all that apply
Open Barbeque Pits
Tableside Cooking
Private Club
Bring your own liquor facility (BYOB)
After hours establishment
Teen dance clubs
Raw seafood served
On premise catering
Off premise catering
Rental of facilities to others
If alcohol is served, what measures are in place for admittance & checking id's on persons under the age of 21 years old?
Your answer
If raw seafood is served, what percentage of sales?
Your answer
If on premise catering, what percentage of sales?
Your answer
If off premise catering, what percentage of sales?
Your answer
If rental of facilities to others, how many times per year?
Your answer
COOKING EXPOSURES
An automatic fire extinguishing system protects hoods, ducts, grease filters and cooking areas including deep fat fryers?
Yes
No
Clear selection
The fire extinguishing system has a manual release located outside the kitchen?
Yes
No
Clear selection
Exhaust filters, ducts and hoods are cleaned by a professional cleaning service quarterly and inspected annually?
Yes
No
Clear selection
Cooking equipment has an automatic fuel shutoff?
Yes
No
Clear selection
Deep fat fryers have a temperature limit with automatic shutoff?
Yes
No
Clear selection
Deep fat fryers are separated from any cooking surface by at least an 18-inch, non-combustible barrier?
Yes
No
Clear selection
Is there any open flame cooking?
Yes
No
Clear selection
Is there proper disposal of trash and smoking materials?
Yes
No
Clear selection
Is there a six month or more frequent service contract in place for the automatic extinguishing system (ansul) system?
Yes
No
Clear selection
SAFETY
Is there an adequate number of fire extinguishers on premises with current service tags?
Yes
No
Clear selection
Does the building have emergency lighting?
Yes
No
Clear selection
Is the building located on wharf, pier, beach, dock or pilings?
Yes
No
Clear selection
Are the steps and rails in good repair with adequate lighting?
Yes
No
Clear selection
Is the building sprinklered?
Yes
No
Clear selection
What percentage?
Your answer
Are there any firearms on premises?
Yes
No
Clear selection
Does insured employ Bouncers?
Yes
No
Clear selection
Number of Bouncers
Your answer
Does insured employ Doormen?
Yes
No
Clear selection
Number of Doormen
Your answer
Does insured employ ID Checkers?
Yes
No
Clear selection
Number of ID Checkers
Your answer
Does insured provide security?
Yes
No
Clear selection
Number of Armed
Your answer
Number of Unarmed
Your answer
Number of Subcontracted
Your answer
If subcontracted are used, are they required to provide COI's evidencing equal or greater GL & WC limits, naming the insured as A/I & have hold harmless agreements in place?
Yes
No
Clear selection
ENTERTAINMENT
Is there a dance floor?
Yes
No
Clear selection
If yes, what is the square footage?
Your answer
Are there bands?
Yes
No
Clear selection
If yes, what type of music?
Option 1
Clear selection
Are there DJ's?
Option 1
Clear selection
If yes, what type of music?
Option 1
Clear selection
Are there pool tables?
Yes
No
Clear selection
If yes, how many?
Your answer
Does insured employ dancers?
Yes
No
Clear selection
Any mechanical bulls or other patron participating activities?
Yes
No
Clear selection
Is there a playroom or playground for children?
Yes
No
Clear selection
Is there any other entertainment?
Yes
No
Clear selection
If so, describe
Your answer
PARKING
Is the parking lot under applicant's control?
Yes
No
Clear selection
Is valet parking provided by your employees?
Yes
No
Clear selection
Is valet parking subcontracted to others?
Yes
No
Clear selection
If yes, does the subcontractor provide certificates of insurance evidencing both auto liability and garage keepers legal liability (GKLL) & hold harmless agreements in place?
Yes
No
Clear selection
LIQUOR LIABILITY
Mono-line Liquor coverage is NOT available
Liquor receipts
Your answer
Limit of Liability Requested
Your answer
Has the establishment received fines, citations or suspensions?
Yes
No
Clear selection
Does the Applicant hold all applicable licenses & permits as required by law?
Yes
No
Clear selection
Is Liquor training provided for active owners, managers, and employees?
Yes
No
Clear selection
If yes, please describe the type of training provided.
Your answer
Is risk located in close proximity to a college or university?
Yes
No
Clear selection
LOSSES
Describe all losses in the past 3 years
Your answer
Have there been any incidents involving Assault & Batter in the past three years? If yes, explain.
Your answer
A copy of your responses will be emailed to the address you provided.
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