Restaurant Supplemental
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Applicant Information
Applicant’s Name
*
Applicant’s Name is required.
Mailing Address 1
Mailing Address 2
City/State/Zip
Select State
New York
California
Texas
Florida
Illinois
Pennsylvania
Ohio
Georgia
North Carolina
Michigan
New Jersey
Virginia
Washington
Massachusetts
Arizona
Indiana
Tennessee
Missouri
Maryland
Wisconsin
Colorado
Minnesota
South Carolina
Alabama
Louisiana
Kentucky
Oregon
Oklahoma
Connecticut
Iowa
Mississippi
Arkansas
Kansas
Utah
Nevada
New Mexico
Nebraska
West Virginia
Idaho
Hawaii
New Hampshire
Maine
Montana
Rhode Island
Delaware
South Dakota
North Dakota
Alaska
District of Columbia
Vermont
Wyoming
County
Requested Effective Date
Website Address
Date Business Started
Business started at same location?
Yes
No
General Information
Type of restaurant (select all that apply)
Bakery
Buffet
Burrito/Taco Shop
Coffee Shop
Cafeteria
Deli
Fine Dining
Family
Fast Food
Sports Bar
Pizzeria
Other
How many years of experience does the current management possess?
0
1
2
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20
What is the restaurant’s total seating capacity?
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50
100
150
200
250
300
Total seating in dining area
0
25
50
100
150
200
Total seating in bar area
0
10
20
30
40
50
Is this a seasonal operation?
Yes
No
Are there take-out operations?
Yes
No
Gross Sales
Food Sales
Liquor Sales
Catering Sales
Total Sales
Has the Applicant maintained an operating profit for the last five years?
Yes
No
If No, please explain
Are bank deposits made daily?
Yes
No
N/A
If No, please describe how money is protected until deposit
Hours of operation
Is this a 24/7 Operation?
Yes
No
Days Closed
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Open
Closed
Days
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Add Hours of Operation
Cooking equipment (enter # of each)
Broilers
0
1
2
3
4
5
Deep Fat Fryers
0
1
2
3
4
5
Grills
0
1
2
3
4
5
Hearth
0
1
2
3
4
5
Oven
0
1
2
3
4
5
Ranges
0
1
2
3
4
5
Other
Fuels used (mark all that apply)
Charcoal
Electric
Gas
Oil
Wood
Other
Catering / Delivery
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Yes to all
Yes
No
Are there any catering operations?
Yes
No
Does the Applicant do any delivery?
Yes
No
If Yes to question #1 or #2, are there any vehicles owned by the applicant?
Yes
No
If Yes to question #1 or #2, are there any employee personal vehicles used?
Number of vehicles owned
0
1
2
3
4
5
# of personal vehicles used
0
1
2
3
4
5
Yes
No
Does applicant check driving records of all drivers?
Yes
No
Does applicant have a vehicle maintenance program in place?
Yes
No
Does the Applicant have valet parking services?
Protection
Clear All
Yes to all
Yes
No
N/A
Is the kitchen equipped with an automatic extinguishing system?
Yes
No
N/A
Does this system cover all cooking and ventilation equipment?
Yes
No
N/A
Is this system UL 300/NFPA compliant?
Yes
No
N/A
Is this system equipped with automatic fuel shutoffs?
Yes
No
N/A
Does this system receive service at least every 6 months?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Is the cooking equipment equipped with remote manual fuel shutoffs?
Yes
No
N/A
Does the Applicant have generators in place to protect stock in the event of a power outage?
Yes
No
N/A
Does the cooking equipment receive regular service?
Yes
No
N/A
Is the equipment serviced by an outside contractor?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Are the cooking areas equipped with non-combustible filters?
Yes
No
NA
Is a cleaning of the hood and duct system performed at least every 6 months?
Yes
No
N/A
Is the hood and duct system cleaned by an outside contractor?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Is the kitchen equipped with UL listed grease extractors?
What is the frequency of cleaning of the grease extractors?
Weekly
Monthly
Annually
Other
Yes
No
N/A
Are the grease extractors cleaned by an outside contractor?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Has all cooking equipment been upgraded within the last 10 years?
If Not, please provide what updates have been completed
Yes
No
N/A
Does the Applicant possess a maintenance agreement on refrigeration equipment?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
General Liability
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Yes to all
Yes
No
N/A
Does the Applicant perform regular sweeping/mopping and/or floor inspections?
Yes
No
N/A
Are logs kept for all cleaning operations?
Yes
No
N/A
Is there a sanitation manager employed with proper hygiene procedures established?
Yes
No
N/A
Does the Applicant contract pest control services?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Does the Applicant contract snow/ice removal?
Yes
No
N/A
Does the Applicant receive a certificate of insurance from the contractor?
Yes
No
N/A
Does the Applicant receive certificates of insurance from all subcontractors?
Yes
No
N/A
Does the Applicant receive certificates of insurance from suppliers?
Yes
No
N/A
Does the Applicant package, repackage, or label any items for sale?
If Yes, please describe
Yes
No
N/A
Is there any cooking at customer’s tables?
Yes
No
N/A
Is there live entertainment and/or dancing on premises?
Yes
No
N/A
Is the parking lot maintained and does it have adequate lighting?
Yes
No
N/A
Is there sponsorship of any sports teams or special events?
If Yes, please describe
Yes
No
N/A
Does the building contain any habitational units?
Yes
No
N/A
Does the Applicant import any food products?
If Yes, what percentages of total
Please describe items
Liquor Liability
Clear All
Yes to all
Yes
No
Are there any Happy Hours or other events when drinks are sold at a lower price?
Yes
No
Are alcohol servers allowed to refuse service to a customer?
Yes
No
Does the Applicant train all employees for Heimlich maneuver and alcohol awareness (TIPS)?
Describe ID checking procedures
How long has the Applicant had a liquor license for this location?
Yes
No
Has the current license or any other license held by the Applicant been suspended or revoked?
Yes
No
Has any fine been paid or citation issued against the Applicant for illegal serving of alcohol?
Yes
No
Is Applicant in compliance with all state requirements for the serving of alcoholic beverages?
Yes
No
Has the Applicant had any alcohol liability claims during the past 5 years?
Yes
No
Has the Applicant ever had a Liquor Liability policy cancelled or nonrenewed?
Worker's Compensation
Clear All
Yes to all
Yes
No
Do you offer health benefits to full time employees?
Yes
No
Do you have a formal written safety program in place and provide ongoing training?
What is the employee turnover percentage on an annual basis?
Do you perform Drug and Alcohol screening?
a. Pre Hire?
Yes
No
b. Post Hire?
Yes
No
Yes
No
Do you provide material handling/lifting training?
What is the maximum weight lifted?
Describe the protection required/provided to prevent slips and falls by employees
Yes
No
Are there quality control measures in place for housekeeping in both the front
Yes
No
Are there quality control measures in place for housekeeping in both the front (public spaces) and back (kitchen/office) areas?
Yes
No
Do you post notices on proper hygiene and provide appropriate training?
Yes
No
Does management have a safety committee that performs and reviews incident/accident investigations?
Please provide number of part time employees
full time employees
Yes
No
Do you provide any employee housing?
Yes
No
Do you provide any employee transportation to and from work?
Yes
No
Do you have a return to work program?
Products Recall
Clear All
Yes to all
Yes
No
Does the Applicant have a formal quality control process?
Yes
No
Is there a recall or market withdrawal plan in place and compliant with FDA guidelines?
Yes
No
Were FDA inspections completed regularly over the last 5 years?
Yes
No
Are there risk transfer procedures in place?
Yes
No
Does the Applicant keep detailed records of products distribution process?
Yes
No
Is there a formal complaint handling process in place?
Yes
No
Have there been any products recall claims in the last 5 years?
If Yes, please describe
Missing Required Information
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Applicant’s Name:
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