The URL can be used to link to this page

Home My Public Portal About2022 SIDEWALK CAFE.pdfCITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION IT I v► 1� Business name .s , L u e r2 VI y J e S 1N c j 0 f Y.}- i, 6 i -F.--t- Street address ZS l it' s4 51- , -1‘-'P- 6.- -1-SLl r\if 1 GA- 3 (3 Q. Ed Mailing address 7 .2. S I Z ("1" 10 ` j- rt yU CIL , 6 a *t 3 Z Name of business owner: 12,10 iV C ,. N )4'0 0 tO Email c� i L tJ e,[ U,/ v{UI��-,' givcb, �f 11 i -f Loc tl -- Phone numbers of owner: Business 31 2 _-1. -6 g SJ C Home Mobile Name of applicant if other than owner: W 1 L n vN ik 00 Email r LtI` 2 WAVE,' r\-) C Y 4 Rio 0 £ rv1 Phone numbers of applicant: Business Home Mobile PP 71 Z - 3 seG -J `� � Relationship of applicant to owner (same, employee, agent, etc.) (- 6 rV G 2 vA L 0AA tv A '2 Mailing address of applicant Q 0 i ,L a e A f i i3 4_ 7Lvt vvo(1 G -A1 3 (3Z ? j Annlie atinn is for: El Sidewalk Cafe ❑ Merchandise Display 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: co f (\ until until until until until until until GO h \ 5 -.op roc\ FOR OFFICE USF ONLY Date Received New or Renewal Ucense Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION E. Affidavit (must be notarized; see page 2) LI Indemnification Agreement (must be notarized; see page 3) Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) O A Site Plan to scale with measurements .of the proposed sidewalk area and all items to be placed on or within it (see page 4) Photograph(s) of the sidew 1k area (itional) Applicant's signature 7 — Printed name \1 w L L 1 rm N, \) O AJ ROUTING APPROVE OR DENY BY DATE FEE Sidewalk Use Fee $0.00 City Marshal An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DIRECT TO THE CITY MANAGER. Planning &Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org Page 1 of 6 12/14/2012 AFFIDAVIT s 1 —Li eTY or\.1 4\0o 1\J , acting in the capacity of N A06) A) owner, agent, employee, etc. name on behalf of the establishment known as 5, LVG-2 -NA! \t6 5 1"K. , (3 'i ►)-1 business name street address , Tybee Island, Georgia, attest to the following: located at o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o There are no omissions of fact. o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o I have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: ) Ye Printed Name: \ 1 L L% Ptrof` ' J INV O N STATE OF GEORGIA COUNTY OF CHATHAM II The foregoing instrument was rknowledued before me this ?"-C' day of vl(�t'tLL.1J&t.LL, 20 ?-2-- , by I— V�`l d�ho is personally known to me or who has produced identification. . �� Q`,NY� p y tilllll/ii ``�0: GREEN �i�•'de ublic hh �j _ --/ �� D�PR j .:mod My Commission expires: ' g1 U `�`� F O0. j " 2 �a U M' Page 2 of 6 1.,c);,-... ,f,q(HAMCO'.%`. Date: g_ ( a vl 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this day of , 20 , by ( LLt A was h ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at ` " ' g , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLIC NT. 5. The terms of this Indemnification eement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, success° and as 'gns. Notarized signature: Printed name: .40' 1 /AA- lamr' Date: tp_67 z STATE OF GEORGIA COUNTY OF CHATHAM nn , }� The foregoing instrument w s cknowledged before me this G day of "� if U\ 202z by who is personally known to me or who has r qi ,,,c ifilivation. Lcoo4N\ f\ ignature of Notary Pub My Commission expires: j G�Q2.\:5 Page 3 of 6 fcL„,,d 12/14/2012 ACG D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/13/2022 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 15 WAIVED, subject to the terms and conditions of the policy, certain policies rhay require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chatham Insurance Partners, LLC 2502 Habersham St. Savannah GA 31401 License#: 202416 CONTACT NAME: Jacquelyn Tucker (A/c No. Ext): 912-650-2808 FAX No): E-MAIL ADDRESS: Jacquelyn@chathaminsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: CINCINNATI INSURANCE COMPANY 10677 INSURED NAVOENT-01 Silver Waves, Inc. Funky Fish, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 INSURER B : INSURER C : INSURER D: INSURER E : INSURER F : CERTIFICATE 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM!DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y ENP 0398909 9/1/2021 9/1/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED 1 RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Aloha Gifts 25 Tybrisa Tybee Island, GA 31328 American Beachwear 17 Tybrisa Tybee Island, GA 31328 Waves 704 1st Street Tybee Island, GA 31328 Island Style 502 1st Street Tybee Island, GA 31328 - Waves 27 Tybrisa Tybee Island, GA 31328 High Tide 406 1st Street Tybee Island, GA 31328 City of Tybee Island 401 Butler Avenue Tybee Island GA 31328 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name 5iL'J ✓i. WnJ,6 5 3-rJGI D6 A- onG2tCAIO 13 On W P ✓?. Street address CI -4 bn.154 bee x.SLANct! 6 A 313 ag 1-4Li Mailing address (.yorL.29-10-, 9llpGE z-fURi,i-ot 1 313Zk Name of business owner: ((,0 NG tv ft‘t 9 IQ Email S1 L UOf—WAVE.T hJ( YI1+QO (ye-i-,\ Phone numbers of owner: Business 12 _i. 1,.4 _ 9 �—o) 4 Home Mobile Name of applicant if other than owner: W i LLo l\-trr, /4 f•ol O Email , j LUC2.v7 itVe N C,6k to 1toc {- -r' Phone numbers of applicant: Business t 2 _116 }, a) 4 Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Coe—nl C (L ra L AA 6 n.l t{ a\"a. Mailing address of applicant Application is for: El Sidewalk Cafe Merchandise Display 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: An - 4'N :06 until OO A> until until until until until until i:00 FOR OFFICE USE ORL Y Date Received New or Renewal License Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION a Affidavit (must be notarized; see page 2) El Indemnification Agreement (must be notarized; see page 3) Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) O A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) O Photograph(s) of the sidewalk area (op,i'i�.nal) Applicant's signature O Printed name \N 1 LU A-rf-r•- ("J f\v Date 1(ZeY2,3 ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org Page 1 of 6 12/14/2012 AFFIDAVIT I, .1 LL i A rr g' 1\0 pi s name owner, agent, employee, etc. , acting in the capacity of (LID N 6 r'1/4.1 A \/O on behalf of the establishment known as VI' IV /CS 0 P 1i_ Arm.: C (+N located at 6fLA Ps S=3 street address business name , Tybee Island, Georgia, attest to the following: o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o There are no omissions of fact. o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o I have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: i Printed Name: l UL i Ia'cr� Nr p(il Or) STATE OF GEORGIA COUNTY OF CHATHAM Date: Z 0/ 4 a — The foregoing instrume t acknowledged before me this day of�� ! , 20 , by 4Sign ture of Notary Publ p .la My Commission expires: Page 2 of 6 who is personally known to me or who ha iir�Ri1uced identification. //g/ `N* GREEN• ,�� `�� ....0\„, ......... �xPi FS Pp;'Y :`�c �y .� : D �. Q U co• W = = -1 �0• > ' �y Pot Cy.: 9,./ 0/4H '•••...„. Q N� . •J�'.� 12/14/2012 s y G , /sR 4r1-IAMAO Aig3 Date: INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this day of , 20 , by 'A../ l.L i i N AU 0 ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at Island, Georgia; and, fliattiS , Tybee WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemni ication A eement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successor and ass _ s. Notarized signature: :'- Printed name., i L Li A r 112.0 STATE OF GEORGIA COUNTY OF CHATHAM The fe erg ,trgment w s Ni Y\ 0 IN) knowledged before me this 2D day of I 20 J , by who is personally known to me oC iigp�.ia ification. 1 i,9• Vi Signature of Notary Public My Commission expires: Page 3 of 6 . a \C) I ma • 1'UB ��' C) 12/14/2012 AcciRai CERTIFICATE OF LIABILITY INSURANCE 1/41.------- DATE(MM/DD/YYYY) 1/13/2022 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 Chatham Insurance Partners, LLC 2502 Habersham St. Savannah GA 31401 License#:202416 CONTACT NAME:ON Jacquelyn Tucker PHONE No, Ext): 912-650-2808 FAX No): E-MAIL ADDREss: Jacquelyn@chathaminsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: CINCINNATI INSURANCE COMPANY 10677 INSURED NAVOENT-01 Silver Waves, Inc. Funky Fish, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 INSURER B : INSURERC: INSURERD: INSURER E : INSURER F : ES CERTIFICATE NUMBER: 250390394 • 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MMDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y ENP 0398909 9/1/2021 9/1/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 P POLICY PRO- II JECT J LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ A ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident ) $ H HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY PER STATUTE OTH- ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y / N N / A E.L. EACH ACCIDENT $ (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Aloha Gifts 25 Tybrisa Tybee Island, GA 31328 American Beachwear 17 Tybrisa Tybee Island, GA 31328 Waves 704 1st Street Tybee Island, GA 31328 Island Style 502 1st Street Tybee Island, GA 31328 Waves 27 Tybrisa Tybee Island, GA 31328 High Tide 406 lst Street Tybee Island, GA 31328 ERTIFICATE HOLDER CANCELLATION City of Tybee Island 401 Butler Avenue Tybee Island GA 31328 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 25 (2014/01) CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name ffj _ 1 6 � 5OK•k.'; � i4 1 �riIvAt,so. 1 1....c.,Street address � 1 uo Mailing address P D. utc, 2 q74' 7 fr �s r j y� G � 3 f 6""� ' Name of business owner: e -PA kQ,,/1? fn Email Phone numbers of owner: Business Home Mobile q /4,65-6_ t / tL Name of applicant if other than owner: Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Mailing address of applicant Application is for: El Sidewalk Cafe Merchandise Display 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Zit" A/n until /2...0 O 6911 g': 0Pmi 6:00 until until until (?i:2DA1/7'l until r: ptl Ain until until !Z ;00 tz: Od Apc I7-'oo An4 Z:Oo #%i' FOR OFFICE USE ONLY oats Receiver! ,Veav or Renewal License Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION Affidavit (must be notarized, see page 2) Indemnification Agreement (must be notarized; see page 3) i( Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) l A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) Photograph(s) of the sidewalk area (optional) Applicant's signature ,8L f "roil Printed name a k J }< a wit 0 Date - 2.?' L2" ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL. TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 1 schaaf(a cityo tybce,or Page 1 of 6 12/14/2012 AFFIDAVIT /13L. 71--4 /' (�,,,, ,,,i , acting in the capacity of Q 64)/Ter mmne owner, agent, employee, etc. on behalf of the establishment known as ercilet 15 -l-: ilu-t'i located at / business name / 3 � «,A 547° 414' , Tybee Island, Georgia, attest to the following: street address q/I have reviewed this application and all entries are correct and accurate to the best of my knowledge. There are no omissions of fact. G./ There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. /No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: ?"-I-have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: Printed Name: kaii-N,`.,6,/ Date: •3_,3• k422 STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this 3I day 4,1/14,a,_, 2Q , by ho is personally known to me or who has produced identification. Signature of Notary Publi Sharon S. Shaver My Commission expires: Nr tanf Public Chath m County, GA My Commission Expires December 4, 2023 12/14/2012 Page 2 of 6 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this 22.1 -1 -day of .e 2022 by kvri;,/ ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at /3 .`J 'C • , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemnification Agreement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successors and assigns. Notarized signature: f� ' .'�` /r,44.0 &FA r» Printed name: Date: 3- 31- 22 STA I E OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this 3' day o ign of Notary . ublic My Commission expires: Page 3 of 6 ,2p ,by o is personally known to me or who has produced identification. Sharon S. Shaver Notary Public, Chatham County, GA My Commission Expires December 4, 2023 12/14/2012 ACCAka CERTIFICATE OF LIABILITY INSURANCE `- DATE(MM/DD/YYYY) 2/22/2022 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 CONSTITU TE 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 Bernard Williams & Company, LLC 6001 Chatham Center Drive Suite 100 Savannah GA 31405 CONTACT Grady Howell NAME: PHONE (912)234-4476 FAX 912)232-fi496 A/C, Na, Ext): (AIC, No): E-MAIL ADDRESS: INSURERS) AFFORDING COVERAGE NAIC 0 INsuRERA:Auto-Owners Insurance Company INSURED BeachBum Boutique, LLC PO Box 2984 Tybee Island GA 31328 I, _ tNSURER B : INSURER C : INSURER D: -INSURER E : t INSURERF: COVERAGES CERTIFICATE NUMBER: 01,2222224011 REVISION NUMBER: TITS iS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS LISTED BROW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TERM OR ':;0NDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS AF) -ORDER BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUDL SF SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR t 906139600 1/13/2022 1/13/2023 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES PREMISES (Ea occurrence) $ 300,000 CLAIMS -MADE X MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'LAGGREGATE GENERAL AGGREGATE $ 2,000,000 i LIMIT APPLIES PER: PRODUCTS - COMP/OPAGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULEI AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ --- BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ --a PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAB .-M.1 DE EACH OCCURRENCE $ ( AGGREGATE $ DED I RETENTION 3 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' (Mandatory in NH) 1 yes, describe under DESCRIPTION OF OPERATIONS Y. / N TORY N / A _ J WC STATU- OTH- LIMITS ER E.L. EACH ACCIDENT $ i below E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT t r-- DESCRIPTION OF OPERATIONS !LOCATIONS / VEHICLES (Attach ACDRD City of Tybee Island is listed as Additional 101, Additional Remarks Schedule, 0 more space is required) Insured CERTIFICATE HOLDER City of Tybee Island Attn: Sharon Shaver 403 Butler Ave Tybee Island, GA 31328 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) INS025 (20100$:.01 T. Brett Goodwin/HH t © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 111 1,.. .� ,r \ [Apt) ► , CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name F An ; es On The 13ea G h Street address 1 co' 3 otam,) D Mailing address ft, Box 3`t _ 66 15. 44,4%3 13 Z? Name of business owner: T ,,,,,,j ..I Ore_ Email -r � n a eS b +12 W oe%4 i) , Gdm Phone numbers of owner: Business 43 (1.-/E4610 G Home 1 Mobile q l Z 6.¢y 597:7 Name of applicant if other than owner: Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, em ee, agent, etc) Mailing address of applicant Application is for: Ti Sidewalk Cafe 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 4:0 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: ri Merchandise Display Co C Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: 11Am Am 1 (AN, until until until until until until [ 2. , eh until 11 e, Il-'M fOR OFFICE USE ONLY Date Received New or Renewal :license Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION Affidavit (must be notarized,• see page 2) Indemnification Agreement (must be notarized see page 3) Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) A Site Plan to scale with measurements of t , - : oposed sidewalk area and all items to be placed on or within it (see page 4) OPhotograph(s) of sidew. area (o Applicant's signature Printed name Date 3 —'1 z -7-- ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org Page 1 of 6 12/14/2012 AFFIDAVIT I, J -C NN f t' -F12 P---- c R.R— , acting in the capacity of D W N 6 (Z -- name owner, agent, employee, etc. on behalf of the establishment known as l to 13 $1i -a-N P F N ►Jt s ON T1-+ Oak C-t-i street address business name , Tybee Island, Georgia, attest to the following: • I have reviewed this application and all entries are correct and accurate to the best of my knowledge. located at q/ There are no omissions of fact. o✓There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o� o violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o I have read the South End P 'cies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Side c Cafe or erchandise Display Permit. Notarized Signature' Printed Name: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this 9 Date: 3 —Z�- t711 day of , 2(i ' "L, by Jem #ii D / I'r who is personally known to me or who has produced identification. qIL-L,Z7t Leryt Sigaure of Notary Public Janet R LeViner NOTARY PUBLIC My Commission expires: CU — - Chatham County, GEORGIA Page 2 of 6 My Commission Expires 10/15/2024 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this `f day of M iL 4i( , 20 ZZ , by IGiNtJ 1 rt ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at t3 S1nAi Ave , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of t i de 'fication Agreem-nt shall be binding upon and inure to the benefit of the parties and their heirs, legal representat es, success s an 1 Notarized signature. Printed name: Date: 3 -R- STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this day o)l ,20 , by UQMi c o f, who is personally known to me or who has produced identification. Sig tore of Notary Public My Commission expires: Page 3 of 6 /0 — / 5 02 5e Janet R LeViner NOTARY PUBLIC Chatham County, GEORGIA My Commission Expires 10/15/2024 12/14/2012 D CERTIFICATE OF LIABILITY INSURANCE '4R DA 4Y 0tY " 8/2 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(les) 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 Tybee Island Insurance Agency Inc P 0 Box 774 Tybee Island. Ga 31328 CONTACT NAME: Carrie Traeger PHONE o EMI: 912-786-5541 FAX No): 012-786 -8707 •MAADDRESS: traegetrallellsouth.net INSURER($) AFFORDING COVERAGE NAIC a INSURER A : Scottsdale INSURED Orriginal Restaurant DBA Fannie on the Beach P O Box 39 Tybee Island, Ga 31328 INSURER Et: 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF IMMIDDIYYYYUMMTDOJYYYYI POLICY EXP LIMITS A GENERAL X LIABIUTY COMMERCIAL GENERAL LIABILITY r'- 1 7S ' CPS7366419 06/04/2021 06/04/2022 EACH OCCURRENCE $ 1,000,000.000 PREMISES (Ea occurrence) $ 100.000.00 ME0 EXP (Any one person) $ 5,000.00 X CLAIMS -MADE OCCUR PERSONAL a Any INJURY $ ( GENERAL AGGREGATE s 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2.000.000.00 GENT- AGGREGATE X POLICY LIMIT APPLIES 7g- _.___. PER: LOC $ AUTOMOBILE LIABIUTY SCHEDULED AUTOS NON-OHIRED AuTosWNED [ L_. (EUa ac tSINGLE LIMIT) BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (Per Orietd) E S UMBRELLJI,LIAB EXCESS LIAS ^OCCUR CAMS MADE EACH OCCURRENCE $ AGGREGATE $ s DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1N ANY PROPRIETOR/PARTNER/EXECUTIVE i iOFFICE/MEMBER EXCLUDED? (Mandatory In NH) dyes, desulbe wider DESCRIPTION OF OPERATIONS below N I A WC STATU- {[0TH• TORY UMRS EL EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ EL DISEASE •POLICY LIMIT 5 Fr DESCRIPTION OF OPERATIONS) LOCATIONS / VEHICLES (Attach ACORD 101. Addtdoeal Remarks Schedule. H mare spate la required) 1613 Stand, Tybee Island Ga 31328.A restaurant bar. The City of Tybee is additional Insured for the tables located on sidewalk outside of restaurant. CERTIFICATE HOLDER City of Tybee Island 401 Butler Ave Tybee Island, Ga 31328 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, R4ED ftEPRESENjATIVEr�� Carrie Traeger/Tybee Island Insurance Agency Inc CD 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD \'Q fz.€7)\9- CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name k>7 t S Street addn*ss 1 LI 1 1 I��ler av L �f Mailingaddress P,©, J7��1_ Sg Tt11'}1L t4+ Ii 1! oA '5 g Name or business owner. L) t `‘ 1 11,16 (l dun Email Phone numbers of owner Business Am. iszt, 4,{170 Home Mobileq 1 Z 3og - q 97 Name of applicant if to than owner. Email Phone numbers of applicant Business Home Mobile Relationship of applicant to owner (same, emplo►ee, agent, etc ) Mailing address of applicant Application is for. Ei Sidewalk Cafe El Merchandise Display 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday. Thursday: Friday: Saturday: 2.. 00 A rti+ until until until until until until until 1Z: 00 Pm PO* orrice useever DIM R.e n.a :per �..� Lions,erwaw Sidewalk elements of cafes and merckandtse displays must be secured daffy when normal business operations cease The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REOUIIZED WITH APPLICATION Affidavit (must be notarized; seepage 2) demnification Agreement (must be notarized; see page 3) z-Certificate(s) of Insurance listing the City f Tybee Island as an additional insured (seepage 4) 1'I A Site Plan to scale with measurement f the proposed sidewalk area and all items to be placed on or within it (see page 4) 0 Photograph(s) of the rldewalk area pti d) Applicant's signature Date Printed name \s % A am t,n QVo ROUTING APPROVZ OR DENY City :Austad Planrong & Zonng Mas itir Page 1 of 6 BY DATE FEE or:rw.lk Use Fee 50.00 403 Butler Avenue, P.O. Box 2749, Tybee lsland, Oeurgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf(rz'cityoftybee.org An applicmas stay requite 30 days or morn to proves D[BECT AN APPEAL OF Y[I Mr' DENIAL TO THE CITY MANAGER 12/14!2412 AFFIDAVIT I, W Z !t.‘ am Ci (twu n on behalf of the establishment lmown as acting in the capacity of Owner , 01671u, agatee'lphwe6,'k. Indiniss am. ly 15 123u,Ir\.r_r' , Tybee Island, Georgia, attest to the following: er I have reviewed this application and all entries are correct and accurate to the best of my knowledge. d There are no omissions of fact. located at There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Reb elation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: /I have read the South End Policies and Proc ores and will abide by said South End Policies and Procedures at all tunes during the term of the Sidewalk Cafe or Mere se Display Permit. Notarized Signature: Qya- Printed Name: //A✓ 1 '1 1/a M, AI Date: / 7/zz7-2:2- STATEE OF GEORGIA COUNTY OF CHATHAM The foregoing in e t was acknowledged before me this t ,71 day of jtLZ2t 1. , 20 t L , by I C.t-t Y1 OA10 b ,i who is personally known to me or who has roduced id entification. y p Signature o My Commission expires: Page 2 af6 12/1.1/2012 Island, Georgia; and, INDEMNIFICATION AGREEMENT (RELEASE AND HOLD IIARMLFSSAGREEMEN7) This Indemnification, Release and Hold l harmless Agreement is made this day of , 20 , b� i7--)‘\.:0+-rn ()&QC) n ("APPLICANT—) for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof; and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at _MI5 litAgz.A.6) , Tybee WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: I. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT, 5. The terms of this Indemnificatii5 A ement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, succ .sors a Notarized signature: Printed name: 1 )1)'el/31,1 AV a- von/ Date: it/ `)/2.-a STATE OF GEORGIA COU t 1 Y OF CHATHAM The foregoing Signature of Notary ' blic My Commission expires: Page 3 of 6 as acknowledged before me this I f day of ; ) �. ` VA LA' ) , 2© , by who is personally known to me or who has caduced identification. Q 0E LLF G,q C.) y i Allele 12114/2012 AC®RD� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 1/13/2022 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(les) 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 endorsements PRODUCER Chatham Insurance Partners, LLC 2502 Habersham St. Savannah GA 31401 INSURED Silver Waves, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 License#: 292416 NAVOENT-01 CONTACT HAKE; Jacquelyn Tucker PHONE _. I;. Nv kw: 912-650-2808 I lA/C E-MAIL (AtC� No): ADDRESS; jacquelynl chathaminsurance.com INSURERS) AFFORDING COVERAGE NAIC a INSURERA: CINCINNATI INSURANCE COMPANY 10677 INSURER 8 : INSURER C INSURER D : INSURER £ INSURER F COVERAGES CERTIFICATE NUMBER: 17125 4977 REVISION NUMBER: THIS INDICATED CERTIFICATE EXCLUSIONS INSR LTR IS TO CERTIFY THAT THE POLICIES OF INSURANCE NOTWITHSTANDING ANY REQUIREMENT. MAY BE ISSUED OR MAY PERTAIN AND CONDITIONS OF SUCH POLICIES. — — � IA�6t)L)'JUBR` TYPE OF INSURANCE WSD 1 wva LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN ISSUED TO THE INSURED CONTRACT OR OTHER THE POLICIES DESCRIBED REDUCED BY PAID CLAMS. I POLICY EFF- TPOLNIYEXP�---__--- IMM IDD/YYYY) IMt//DDiYYYY1 NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, i POLICY NUMBER LIMITS A X COMMERCIAL GENERAL UABIUTY CLAIMS -MADE -X j OCCUR Y ENP 0398905 i 9/1/2021 9/1,2022 I _ EACH OCCURRENCE tiATtA-GrrO RT'NfED — PREMISES (Ea ocrurrencej S 1 11,0.(1,,0 5 500 000 GEM. MED EXP (Any one person) - - $ 5,000 AGGREGATE LIMIT APPLIES PER: PRO- -1 PERSONAL 6 ADV INJURY i 5 1_000,050 1 5 2_000;::00 GENERAL AGGREGATE — PRODUCTS - COMP/OP AGL, L5 2_000.000 -.. __ AUTOMOBILE LIABILITY ANY AuTo _ ALL OWNED SCHEDULED . _ . AUTOS Aril is rrtfN-OWNED HIRED AUTOS AUTOS _ .. 1 COMBINED SINGLE LIMIT 15 L acciden! BODILY INJURY (Per person) 5 BODILY INJURY (Per accident) - _ S PROPERTY DAMAGE (Per accjclenti_ S -_ - } UMBRELLA LIAR _ _ - .00CUR EXCESS LIAB CLAIMS -MADE I EACH OCCURRENCE # S LAGGREGATE 1 $ T , DEO . , RETENTIONS (ANY WORKERS AND OFFICEIMEMBER (Mandatory If yes, DESCRIPTION COMPENSATION EMPLOYERS' LIABILITY YIN N (A I PER I OTH- —,_1 STATUTE J ER E.L. EACH ACCIDENT PROPRIETOR'PARTNER/EXECUTIVE ExCLUDED'" E.L DISEASE - EA EMPLOYE M NH) describe under OF OPERATIONS below ----- E.L. DISEASE - POLICY OMIT 1 $ DESCRIPTION OF OPERATIONS ( LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space Is required) City of Tybee Island is listed as Additional Insured as required by written contract with respect to the following locations: 17 Tybrisa Ave, Tybee Island, GA 31328 (Silver Waves Inc.) 23 Tybrisa St. Tybee Island, GA 31328 (Funky Fish, Inc.) 25 Tybrisa Ave, Tybee Island, GA 31328 (Silver Waves, Inc.) 27 Tybrisa Ave, Tybee Island, GA 31328 (Silver Waves, Inc.) 201 McKenzie Ave, Tybee Island, GA 31328 (201 McKenzie, LLC) 211 Butler Ave, Tybee Island, GA 31328 (Funky Fish, Inc.) 406 US Hwy 80, Tybee Island, GA 31328 (406 US Hwy 80, LLC) See Attached... CERTIFICATE HOLDER CANCELLATION City of Tybee Island 401 Butler Avenue Tybee Island GA 31328 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name iZ O c 440 V SC r -r G e• l. Street address ( G i 5 v+, cf Ave `� ioC e Mailing address r D 6,--x 976 Name of business owner: \-1-051,0) a G -V Oy� Email • "N L «-1- p r (� q . Q i' • C d ✓ik Phone numbers of owner: Business 9/2,7 grin��i ll Home 1 ✓ Mobile 3O S' 7116- y 7c -1f Name of applicant if other than owner: Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Mailing address of applicant Application is for: 121 Sidewalk Cafe 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: CO:o0 Aim until until until until until until until /O ' °o V f1 Merchandise Display 7`-/' Y 3' FOR OFFICE 05E ONLY Data Received New or Renewal License Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION 0 t's,A-c;r'ij Applicant's signature ,/ Printed name 51 U 0. N 0 - Affidavit (must be notarized; see page 2) Indemnification Agreement (must be notarized; see page 3) Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) Photograph(s) of the sid walk area/optional) Date (9 ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERbIIT DENIAL TO THE CITY MANAGER Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 1 'o laa fti'cityoftv ?eE.'..11l`ct Page 1 of 6 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS �AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this / 0 h day of Oita r G , 20,2 , by D a./0- a 5 )) a. vN ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referre to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. (� �f �j WHEREAS, the APPLICANT is the owner or lessee of the property located at � S 18 4� 0 I Ic'r JT"�-- , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemnification Agreement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successofs and assigns. Notarized signature: Printed name: j drj i1 v a --5//' 072,R. Date: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged bef`il s !O �� ll day of ►� ..aA GL. , 20;? , by hi) �� wy�s 3` `y n to me or who has produced identification. .7,0 aal : Agc y 1154 ir{ 2025 (mss . 111111Ol Sign `ure of Not 'Public My Commission expires: Page 3 of 6 12/14/2012 AFFIDAVIT I, ([0511 v a IMO- \) a� , acting in the capacity of p r name owner, agent, employee, etc. lac +6, 5,e- I f on behalf of the establishment known as 5 -Nerstree1t4 0e:e—_- address business name , Tybee Island, Georgia, attest to the following: located at o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o There are no omissions of fact. o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o 1 have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: Printed Name: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this MA day of J os V� N av°h Signature of Not My Commission expires: Page 2 of 6 Date: W`acL 3/io/aa- ,20 a? ,by who .im rsona11y known to me or who has produced identification. 01 so O�JMISS/ON. e'• 14 G f>�S li i N A•1 _a = rn M02C ti • 2025 v 0•�••'•.4 COUNT y ••�•0 iR I, FU`0`. 12/14/2012 A a® CERTIFICATE OF LIABILITY INSURANCE DATE 3�11�2022YY) 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 Bernard Williams & Company, LLC 6001 Chatham Center Drive Suite 100 Savannah GA 31405 CONTACT Grady Howell NAME: PHONE (912)234-4476 FAX .Fxt). No): (912)232-9490 AAA ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:JameS River Insurance Company INSURED Bikinis, Inc, DBA: Rockhouse Bar & Grill PO Box 276 Tybee Island GA 31328 INSURERB:HudSon Specialty INSURERC: INSURER D: INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER:CL2231124101 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 QF 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 LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY 00121855-0 9/15/2021 9/15/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 50,000 MED EXP (Any one person) $ Excluded CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE I POLICY LIMIT APPLIES PRO JE(:T PER: LOC $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WC STATU- TORY LIMITS OTF)- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Liquor Liability HSLL47533 9/15/2021 9/15/2022 Each Occurrence $1,000,000 General Aggregate $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Tybee Island is listed as Additional Insured. CERTIFICATE HOLDER CANCELLATION The City of Tybee 103 Butler Ave Tybee Island, GA I Island SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T. Brett Goodwin/HH — © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) INS025 (201005).01 The ACORD name and logo are registered marks of ACORD CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name 50,1 5E44 e_. 51--D v 1 c• Street address Mailing addres IOt2_ f c ir' C.r ( 44%1C- %►-t IL7 r r.� � A / �1 31 5( Name of business owner: ✓�" nt cx ' Wilt-ye.Cj Email .,",� C ei 9 414,.-5r—C7S OL' Jw...: I • i Phone numbers of owner: Business Home /it3 Mobile Name of applicant if other than owner: Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) .01 Yi rvi Mailing address of applicant /10/2.. / / 4v £ , 1/ c. 3/N-1-1; 72"--/,...1 Application is for: El Sidewalk Cafe 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: /el until q d Monday: ! until / IO�*�.. Tuesday: % lM until 9 A.ti Wednesday: 11 until /414 Thursday: / � until Friday: _) (fir. until ! P ^- Saturday: 1 per- until Ori ElMerchandise Display — (13ci) FOR OFFICE USE ONLY DDate:ecaived New Renewal Lkense Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION r" Affidavit (must be notarized; see page 2) Indemnification Agreement (must be notarized; see page 3) /Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) \ A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) OPhotograph(s) of the sidew e .(optional) Applicant's signature Printed name Date ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org P Page 1 of 6 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASEAND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this 2L/ day of A ._ ,2027, ,by CLM. a GS ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When refe d to here' e CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at t 5' Y a'c5G— ST , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this lndemnificati. , . - ent shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successo Notarized signature: Printed name: Date: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this a5-- day of , 20 a2- , by who is personally known to me or who has produced identification. She of Notary Pub My Commission expires: Page 3 of 6 Sharon S. shaver Notary Public, Chatham County, GA My Commission Expires December 4, 2023 12/14/2012 AFFIDAVIT 5 on behalf of the establisl nt known as , acting in the capacity of ownerowner, agent, employee, business name Tybee Island, Georgia, attest to the following: r/ street address es' I have reviewed this application and all entries are correct and accurate to the best of my knowledge. There are no omissions of fact. located at There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. e5 No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: a/ 1 have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe rchandise Display Permit. Notarized Signature: Ju , / Date: Printed Name: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this Signature of Notary Public My Commission expires: Page 2 of 6 day of lyt CA , 20 7,— , by who is personally known to me or who has produced identification. Sharon S. Shaver Notary Public, Chatham County, GA r'nrnmission Expires December 4, 2023 12/14/2012 ACORL�� COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION AGENCY Remer Lane Insurance PO Box 14514 8401 Waters Ave Savannah, GA 31416-1514 CONTACT Jonathan B. Lane NAME: PHONE () 912 352/1444 (A/C. No. Ext): FAX Not- (912) 352-2500 E-MAIL info@remerlane.com ADDRESS: CODE: AGENCY CUSTOMER ID: 062106211543017 LINES OF BUSINESS SUBCODE: CARRIER Maxum Indemnity Company DATE(MMIDD(YYYY) 03/01/2022 COMPANY POLICY OR PROGRAM NAME POLICY NUMBER ZZ UNDERWRITER STATUS OF TRANSACTION QUOTE 23 AL NDERWRITER OFFICE NAIC CODE PROGRAM CODE ISSUE POLICY I I RENEW BOUND (Give Dale and/or Attach Copy): CHANGE DATE CANCEL TIME INDICATE LINES OF BUSINESS BOILER & MACHINERY BUSINESS AUTO BUSINESS OWNERS COMMERCIAL GENERAL LIABILITY ✓ COMMERCIAL INLAND MARINE COMMERCIAL PROPERTY CRIME ATTACHMENTS ACCOUNTS RECEIVABLE / VALUABLE PAPERS GLASS AND SIGN SECTION STATEMENT / SCHEDULE OF VALUES ADDITIONAL INTEREST SCHEDULE HOTEL / MOTEL SUPPLEMENT STATE SUPPLEMENT (If applicable) ADDITIONAL PREMISES INFORMATION SCHEDULE INSTALLATION/ BUILDERS RISK SECTION VACANT BUILDING SUPPLEMENT APARTMENT BUILDING SUPPLEMENT INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE CONDO ASSN BYLAWS (for D&O Coverage only) INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT _ CONTRACTORS SUPPLEMENT LOSS SUMMARY COVERAGES SCHEDULE OPEN CARGO SECTION DEALERS SECTION PREMIUM PAYMENT SUPPLEMENT DRIVER INFORMATION SCHEDULE PROFESSIONAL LIABILITY SUPPLEMENT ELECTRONIC DATA PROCESSING SECTION RESTAURANT / TAVERN SUPPLEMENT PREMIUM $ $ CYBER AND PRIVACY FIDUCIARY LIABILITY $1859.00 PREMIUM GARAGE AND DEALERS LIQUOR LIABILITY MOTOR CARRIER TRUCKERS UMBRELLA YACHT AM PM PREMIUM $ $ POLICY INFOR PROPOSED EFF DATE 3/26/2022 NIATION MINIMUM PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT PREMIUM POLICY PREMIUM $ $ $ 3/26/2023 DIRECT ✓ AGENCY APPLICANT INFORMATION NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) LEMON HOPS LLC dba SEASIDE SWEETS 1012 LAUREL AVE Tybee Island, GA 31328 GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: (678) 613-4225 WEBSITE ADDRESS CORPORATION INDIVIDUAL JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS: NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NOT FOR PROFIT ORG PARTNERSHIP GL CODE SUBCHAPTER "S" CORPORATION TRUST SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION INDIVIDUAL JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS - NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NOT FOR PROFIT ORG PARTNERSHIP GL CODE SUBCHAPTER "S" CORPORATION TRUST SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION INDIVIDUAL ACORD 125 (2016(03) JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS - NOT FOR PROFIT ORG PARTNERSHIP SUBCHAPTER "S" CORPORATION TRUST u Page 1 of 4 ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD APPLICANT INFORMATION NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) LEMON HOPS LLC dba SEASIDE SWEETS 1012 LAUREL AVE Tybee Island, GA 31328 GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: (678) 613-4225 WEBSITE ADDRESS CORPORATION INDIVIDUAL JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS: NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NOT FOR PROFIT ORG PARTNERSHIP GL CODE SUBCHAPTER "S" CORPORATION TRUST SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION INDIVIDUAL JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS - NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NOT FOR PROFIT ORG PARTNERSHIP GL CODE SUBCHAPTER "S" CORPORATION TRUST SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION INDIVIDUAL ACORD 125 (2016(03) JOINT VENTURE NO. OF MEMBERS LLC AND MANAGERS - NOT FOR PROFIT ORG PARTNERSHIP SUBCHAPTER "S" CORPORATION TRUST u Page 1 of 4 ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: DB2106211543017 ADDITIONAL INTEREST/ CERTIFICATE RECIPIENT IN TE NAME AND ADDRESS RANK: CITY OF TYBEE ISLAND PO BOX 2749 TYBEE ISLAND, GA 31328 J REST ADDITIONALINSURED EMPLOYEE AS LESSOR LENDER'S LOSS PAYABLE LIENHOLDER LOSS PAYEE MORTGAGEE ACORD 45 attached for additional names EVIDENCE: I I CERTIFICATE REFERENCE / LOAN #: CG20260413 INTEREST IN ITEM NUMBER LOCATION: ITEM CLASS: ITEM DESCRIPTION BUILDING: REM: GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES (For all past or present operations) 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? 5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (Y/N) SMALL TOOLS LARGE EQUIPMENT SMALL TOOLS LARGE EQUIPMENT 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? 7. ANY PARKING FACILITIES OWNED/RENTED? 8. IS A FEE CHARGED FOR PARKING? 9. RECREATION FACILITIES PROVIDED? 10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES". answer the following): # APTS TOTAL APT AREA Sq. Ft. DESCRIBE OTHER LODGING OPERATIONS 11. IS THERE A —7 APPROVED SWIMMING POOL ON PREMISES? FENCE n LIMITED ACCESS (Check all that apply) DIVING BOARD n SLIDE n ABOVE GROUND — IN GROUND n LIFE GUARD 12. ARE SOCIAL EVENTS SPONSORED? SPONSORED? 13. ARE ATHLETIC TEAMS TYPE OF SPORT CONTACT SPORT (Y/N) AGE GROUP 12 & UNDER — 13 - 18 OVER 18 TYPE OF SPORT CONTACT SPORT (YIN) AGE _ GROUP 12 & UNDER 13 - 18 OVER 18 EXTENT OF SPONSORSHIP: EXTENT OF SPONSORSHIP: 14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? 15. AN ACORD 126 (2016/09) Page 3 of 4 £tdt $ cc -#'S rt, r ••• 1- it; r x tnJ� ctti NY ,/ // 0E4 514` t C�CtJ� ✓' �i /// .rte 5. CITY OF Tyr BEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name SQQ, lw L1N5 Street address A —2r i S Q- s _.}.pr T f 1 Mailing address 4 CAF 5$5 -T 15{tZrlJ C/L?sj3jZg Nameofbusmess owner: w. i\iC1,m 1 (Q.UOn Email -Z-5i }S q)10t7. CAM Phone numbers of owner. Business 0,1 Home • '1754 • 1 b Mobile qty.. -9ta4 Name of applicant if other than owe Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Mailing address of applicant Application is for. U Sidewalk Cafe 121 Merchandise Display 1. The length and width in feet of the public right -0f --way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: until Tuesday: until Wednesday: until Thursday: until Friday: until Saturday: '✓ until 1•• 00 11m until %'2. oO PM ran OMrFmo° aAKY Deft Recto J Newts Renewal' Le&ee xtrafte Sidewalk dements of cafes and merchandise displays must be secured daily when normal business operations cease The applicant shall not replace the approved items or chance the layout without written authorization from the Planning and Zoning Manager. DO IJMENTS R>;•.OUIRED WITH APPLICATION al 9ffidavit (must be notarized; seepage 2) ;P',Indemnification Agreement (must be notarized; seepage 3) Cr Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (seepage 4) A Site Plan to scale with measurement the proposed sidewalk area and all items tci be placed on or within it (seepage 4) Photogaph(s) of the sidewalk area Applicant's signature (� Printed name (\.I ; t`�a(i\ 1 \(w u n APPROVE OR DENY City Marshal QilaaPg & Zoning Mast r Date BY DATE EEL Sidewalk Use Fee 5000 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoitybee.arg Page I of 6 An application nay require ?0 days or more to RTALIS DIRECT AN AP'EAL OF PEWIT DENIAL TO TAE CITY MANAGER 12/74/2012 AFFIDAVIT L LLYAtiti,n1 Ow) s (7, \\.s on behalf of the establishment known as Am T4)r`l`a sorer ad3wa , acting in the capacity of name owner r pwnrr, GSM Tybee Island, Georgia, attest to the following: o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o./ There are no omissions of fact. located at o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafes or Merchandise Display Permit. or No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or- y' The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: / 1 have read the South End Policies and Pro edures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Ca4 or Merchgadt`se Display Permit. Notarized Signature: ' Date: .a u7A( Printed Name: STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrume Si nature ofNotary 'Public My Commission expir Page 2 of 6 ///1/2-2, acknowledged before me this I -7 day oft U" 'k- , 20 , by who is personally !mown to me or who has produced identification. Zg, 12/14/2012 INDEMMFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this day of , 20 , by 1.) i t1i 'C.t M t t I -0I'1 ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CTIY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. �] WHEREAS, the APPLICANT is the owner or lessee of the property located at c�3 ibrl sa JT • , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and bas obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: I. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family. officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claimc or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT.. 5. The terms of this Indemnificatio %Agr ent shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successors an si } Notarized signature: Printed name: t/ . t 1'i /1M V " V t/V Date: 1 r t -7 /7,020/ STATE OF GEORGIA COUNTY OF CHATHAM The foregoing ins Ilia (kW Y1 Signature of Notary ent was acknowledged before me this day of u1L' .Litf,L 17, / , 2672 , by who is personally known to me or who has produed identification. ‘‘0.1.1111/../:1,lLE?.4:9;:./v/e My Commission expires: Page3 f6 i�.. �1 .��VQ.SgtO o�i w U S` v CC V i \ ii.ff j'Itiltisit00 12/14/2012 AGENCY CUSTOMER ID: NAVOENT-01 LOC #: AC R ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Chatham Insurance Partners, LLC NAMED INSURED Silver Waves, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 502 1st Street, Tybee Island, GA 31328 (Silver Waves, Inc.) 704 1st St. Tybee Island, GA 31328 (Southeast Marketing (USA), LLC) 1415 Butler Ave, Tybee Island, GA 31328 (Funky Fish, Inc.) ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACCaRD THISCRTIFICATE 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 DATE (MM/DD/YYYY) 1/13/2022 CERTIFICATE OF LIABILITY INSURANCE PRODUCER Chatham Insurance Partners, LLC 2502 Habersham St. Savannah GA 31401 INSURED Silver Waves, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 License#: 202416 NAVOENT-01 41 CONTACT NAME_ Jacquelyn Tucker PHONE i FAX Ext): 912-650-2808 i (A/C, No): ADDREssJacqueiyn@chathaminsurance.com INSURER(5) AFFORDING COVERAGE NAIC INSURER A : CINCINNATI INSURANCE COMPANY 10677 NSURER 8 : INSURER C INSURER D INSURER E : INSURER F REVISION NUMBER: t.05.0 VlvO Y cl G vr. - . a. .....� .-..._...._ _... .. . _.... ... 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 LTR —ADDL.SUOR f TYPE OF INSURANCE WSD I WVD POLICY NUMBER POLICY EFF POLICY EXP (MMDDIYYYYI (MM/OD/YYYY) LIMITS A X f COMMERCIAL GENERAL. LIABILITY Y ENP 039890. 1 9/1/2021 1 911 2022 EACH OCCURRENCE $ 1 000,000__ —t- i 1 CLAIMS ! X i OCCUR A AG�'�ro RENTED PREMISES (Ea occurrence) 5 500,000 -MADE MED EXP (Any one peesun) $ 5,000 PERSONAL & AOV INJURY 5 1,000.000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L _ I PRO- 1 ' LOG ?PRODUCTS - COMP/OP AGG $ 2,000,000 POIC LY _ __j JECT L, __ OTHER $ AUTOMOBILE LIABILITY 3 I { ; COMBINED SINGLE LIMIT (Ea accident) 1 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED I SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED PROPERTY DAMAGE (Per accident) $ ,._..— HIRED AUTOS AUTOS LIAB OCCUR EACH OCCURRENCE iUMBRELLA EXCESS LIAR AGGREGATE 5 CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION 1 PER 1 1OTR H- i STATUTE I ___ AND EMPLOYERS' LIABILITY Y/N ANY PROPRtETOR1PARTNER/EX£GUTIV£ E.L. EACH ACCIDENT 5 OFFICER'MEMBER EXCLUDED? in NH) N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory if yes. describe under DESCRIPTION OF OPERATIONS below j E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) City of Tybee Island is listed as Additional Insured as required by written contract with respect to the following locations: 17 Tybrisa Ave, Tybee Island, GA 31328 (Silver Waves Inc.) 23 Tybrisa St, Tybee Island, GA 31328 (Funky Fish, Inc.) 25 Tybrisa Ave, Tybee Island, GA 31328 Silver Waves, Inc.) 27 Tybrisa Ave, Tybee Island, GA 31328 (Silver Waves, Inc.) 201 McKenzie Ave, Tybee Island, GA 31328 (201 McKenzie, LLC) 211 Butler Ave, Tybee Island, GA 31328 (Funky Fish, Inc.) 406 US Hwy 80, Tybee Island, GA 31328 (406 US Hwy 80, LLC) See Attached,.. CERTIFICATE HOLDER CANCEL City of Tybee Island 401 Butler Avenue Tybee Island GA 31328 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD -,ss b •I* 144. 5" I I s 0c4 CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name T CA —No '- ( Q-0 . Street address �- `S s -i.._ b2 _,r, t7 \ 3 l 3 Mailing address ?. O . .44.w..) -t h4_4... ..1SwknnL CSL t4 at 33t Name of business owner: ,KQt e.)00 --S civ� Email G Qa ��V\ "io i f -e, Phone numbers of owner: Business `a -- -4,66 .t, „.s.,( Home q obile Name of applicant if other than owner: Email Phone numbers of applicant: Business 91 a _ i-'T,5(Ls , 4 st k Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Mailing address of applicant Application is for: Sidewalk Cafe 1. The length and width in feet of the public right-of-way to be used: 3 Q{' —4,s-- 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: 1 (gin until 1 Monday: q ekkn until cl cir(Yl Tuesday: q uoty-i until q 1 Wednesday: 9 ci- AIN until n ()fn Merchandise Display FOR OFFICE USE ONLY Date Received New or Renewal License Number Thursday: q ck, s until q ron Friday: q until r ?Iv') Saturday: f Cu, until q V8iVI Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION 1 Affidavit (must be notarized; see page 2) ® Indemnification Agreement (must be notarized; see page 3) K Certificate(s) of Insurance listing the City of Tyhee Island as an additional insured (seepage 4) A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) Photograph(s) of the sidewalk area (optional) Applicant's signature Printed name Date ROUTING APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org Page 1 of 6 12/74/2012 AFFIDAVIT I, , acting in the capacity of name owner, agent, employee, etc. on behalf of the establishment known as T. business name street address , Tybee Island, Georgia, attest to the following: located at o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o There are no omissions of fact. o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o I have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: Printed Name: z ail 1106 Date: ollq/c2Q STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this /1/' day of , 20 g � by /c--kicuz /�—`Z -e_5S who is personally known to me or w o has produced identification. Sign e of Notary Public My Commission expires: %O Page 2 of 6 Janet R LeViner NOTARY PUBLIC Chatham County, GEORGIA jli!v G`q.TIIrytiicCinn An 1.1 r_ 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this day of , 20 , by ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at , Tybee Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemnification Agreement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successors and a" signs. Notarized signature: ` (f, Printed name: Wj (Ch-A-�/ 0 e�S Date: 0/1/14702 STATE OF GEORGIA COUNTY OF CHATHAM The foregoing instrument was acknowledged before me this / V. day of , 20eA - by /) ) /C /q.CL 2 1.,._64.&->' who is personally known to me or who has produ ed identification. Ol Signat re o Notary Public My Commission expires: / 0 Page 3 of 6 Janet R LeViner NOTARY PUBLIC Chatham County, GEORGIA My Commission Expires 10/15/2024 12/14/2012 !`�D0 CERTIFICATE OF LIABILITY INSURANCE TE DA 01/14/2022 ) 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 have ADDITIONAL INSURED provisions or be endorsed. If SJBROGATION 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 endarsement(s). ?RODU-ZER 'CONTACT Remer Lane Insurance PO Box 14514 8401 Waters Ave Savannah, GA 314161514 Brinson Lane NAME. We io. EMI: NE 912-352-4444 FAX No): 912-352-2500 L ADa ESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: LLOYDS OF LONDON LLD FteSUR.ED T.S. CHU AND COMPANY, INC. P.O. BOX 700 TYBEE ISLAND, GA 31328 INSURER B : USLI 25898 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 NDICATED. 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 LTR TYPE OF INSURANCE ADDL INSD SUER WVD POLICY NUMBER POLICY EFF IMM(DD/YYYY) POLICY EXP fliEWDD/YYYY1 LIMITS A COMMERCIAL GENERAL LIABILITY 21699GAPKG 08/12/2021 08/12/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE rOCCUR MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES JECT PRO- PER: LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER STATUTE ERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ B Liquor Liability LQ1005626 12/06/2021 12/06/2022 Occurrence Aggregate 1,000,000 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF TYBEE ISLAND PO BOX 2749 403 BUTLER AVE. TYBEE ISLAND, GA 31328 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 4/14 47.4 ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Business name Street address Mailing address Name of business owner: (Lo (t Vt' o rJ Phone numbers of owner: Business ,-.)lZ X6 _.4�Z 5 �, Home CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION jLtJ Q Ni4'NJ LS -1-NC- , 0$:1— \ VG-� ' Q -tV,v5 5 1fi zi•,jUt1 6* 3c3ZY Ln - o( 6 Email Name of applicant if other than owner: W t rrr,. N p 0.0 'NJ Phone numbers of applicant: Business -. t 2. $6 Home Relationship of applicant to owner (same. employee, agent, etc.) C>aG—nIC., rjoiL /Val:. P.t (V A C >2 Mailing address of applicant 1' .O . ` 2 `(1 , � -SS LA nlCi G Application is for: Sidewalk Cafe Merchandise Display Mobile 1. The length and width in feet of the public right-of-way to be used: 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: 8.00 Ai N Pori*. until until until until until until until 4:00 e Email Mobile FOR OFFICE USE ONLY Date Re ived Nev or Renewal License Number Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION Affidavit (must be notarized; see page 2) Et. Indemnification Agreement (must be notarized; see page 3) Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) D A Site Plan to scale with measuremen .of ovl proposed sidewalk area and all items to be placed on or within it (see page 4) O Photograph(s) of the sidewalk area ptiona) Applicant's signature Printed name \i\i i AM t\is 0 ROUTING City Marshal Planning & Zoning Manager APPROVE OR DENY BY Date FEE DATE 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org Sidewalk Use Fee $0.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Page 1 of 6 12/14/2012 AFFIDAVIT 1, • N 410“)(\i name , acting in the capacity of YtO c r J (\J AU OJ owner, agent, employee, etc. on behalf of the establishment known as t LLI G''t— v business name , Tybee Island, Georgia, attest to the following: street street address located at o I have reviewed this application and all entries are correct and accurate to the best of my knowledge. o There are no omissions of fact. o There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. o No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: o I have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: `/- Printed Name: VT f L I P 141-1,f\_ N\I STATE OF GEORGIA COUNTY OF CHATHAM The foregoing (11i 11jv►n GWM Signature of Notary P My Commission expires: Page 2 of 6 0� Date: (/20/2-4 instrume t acknowledged before me this ZZ day of 2 , 20 by `,,��1%1111 who is personally known to me or who � t t'G}cation. p y ,z;" ' ,oMMisso • 2 s ' SOP:. ``t�rn a : '9,c St m P :� °LIG .• .... .. .. `69'' N▪ ry 2e 202„- 12/14/2012 INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this day of , 20 , by L_L f ikrr r\rft\} ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemnification A eement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successors and as s. Notarized signature: L. Printed name: \A) (L(. i rI 24 Date: !1 iNifI rbAj STATE OF GEORGIA COUNTY OF CHATHAM The forgoing instrument was cknowledged before me this 20 ijd I ' " who is personally known to me or who has produce • identification. \,ANE4 .,,,(\;;;c3.0.;;;; Sipti...Ci�**! c� e�G - •41,Q� AD Z 7. 13'4I •`' y ; .y:� 'OLIO �.�"'�•GC;28 2O2:/(:)Q(sS Signature of Notary Pub My Commission expires: Page 3 of 6 !Ai day of ALL ,20'a ,by , Tybee 12/14/2012 '`�'� RD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 1/13/2022 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 /bay require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Chatham Insurance Partners, LLC 2502 Habersham St. Savannah GA 31401 License#: 202416 CONTACT NAME: Jacquelyn Tucker (A/c No. Exj): 912-650-2808 FAX No): E-MAILADDRESS: ADDREss: jacquelyn@chathaminsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: CINCINNATI INSURANCE COMPANY 10677 INSURED NAVOENT-01 Silver Waves, Inc. Funky Fish, Inc. Insurance Department P.O. Box 2497 Tybee Island GA 31328 INSURER B : INSURERC: INSURER D : INSURER E INSURER F : CERTIFICATE NUMBER: 250 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP INIM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY Y ENP 0398909 9/1/2021 9/1/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PRO - JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY(Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERJEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Aloha Gifts 25 Tybrisa Tybee Island, GA 31328 American Beachwear 17 Tybrisa Tybee Island, GA 31328 Waves 704 1st Street Tybee Island, GA 31328 Island Style 502 1st Street Tybee Island, GA 31328 - Waves 27 Tybrisa Tybee Island, GA 31328 High Tide 406 1st Street Tybee Island, GA 31328 CANCELLATION City of Tybee Island 401 Butler Avenue Tybee Island GA 31328 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CITY OF TYBEE ISLAND SIDEWALK CAFE OR MERCHANDISE DISPLAY PERMIT APPLICATION Business name --Ty ) CZ. 7'5 \CLYNCA ,' tAD; Ili es LLG. Street address 1 tP $ Ty b `, sa.- 3'trr -f - Mailing address 'P O. Bac 6201 a-7 3gveunvutih CA X31 L -{-a0 Name of business owner: W i lit i 0.M D c_14.; nS Ch Email C-Cit, 1 L i Ins e We.* w d tN as , C o INA._ Phone numbers of owner: Business (q12)920_s-&5•0 Home C9 13)3 J5-5-_ 5.5330 Mobile (co 2) 5ci 10 �S�,p50 / Name of applicant if other than owner: Email Phone numbers of applicant: Business Home Mobile Relationship of applicant to owner (same, employee, agent, etc.) Mailing address of applicant Application is for: ErSidewalk Cafe Merchandise Display 1. The length and width in feet of the public right-of-way to be used: 10'9" 2. The number of tables and chairs to be provided at the Sidewalk Cafe: 5 `}'a -b.1 e 5 - 10 , rs 3. Hours of operation of the Sidewalk Cafe or Merchandise Display: Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: ol�+n until i, a '► Gi curl until ) a O 4yrl qeon ci any\ 431 0.M ark until ` a rY-1 until 6 a a rn until , a cz m until 1 a r'n until 1 clay-) FAR OFFICE USE ONL Y i.rnn Received Hew or Renewal License .5,loother Sidewalk elements of cafes and merchandise displays must be secured daily when normal business operations cease. The applicant shall not replace the approved items or change the layout without written authorization from the Planning and Zoning Manager. DOCUMENTS REQUIRED WITH APPLICATION 51' Affidavit (must be notarized;see page 2) re Indemnification Agreement (must be notarized; see page 3) d". Certificate(s) of Insurance listing the City of Tybee Island as an additional insured (see page 4) Lti ( A Site Plan to scale with measurements of the proposed sidewalk area and all items to be placed on or within it (see page 4) O Photograph(s) of the sidewalk area (optional) Applicant's signature Printed name W 11; Date ROUTLNG APPROVE OR DENY BY DATE FEE City Marshal Sidewalk Use Fee 00.00 An application may require 30 days or more to process. DIRECT AN APPEAL OF PERMIT DENIAL TO THE CITY MANAGER. Planning & Zoning Manager 403 Butler Avenue, P.O. Box 2749, Tybee Island, Georgia 31328 (912) 472-5033 FAX (912) 786-9539 Lschaaf@cityoftybee.org cityoftybee.org Page 1 of 6 12/14/2012 AFFIDAVIT I, W : t i Gt_.M ]: < ; v15 0 Y1 , acting in the capacity of C) W Ar name — owner, agent, employee, etc. on behalf of the establishment known as 71 S111nnc we+ (.4):i 1 rti5 business name f'illr►sa streetaddressaddress LLB , Tybee Island, Georgia, attest to the following: located at G/1 have reviewed this application and all entries are correct and accurate to the best of my knowledge. (3,7 There are no omissions of fact. cyt There are no items located on the sidewalk where the Sidewalk Cafe or Merchandise Display is proposed that would prohibit the Planning and Zoning Manager from issuing a Sidewalk Cafe or Merchandise Display Permit. ,/ No violation(s) of Georgia Law, Federal Law, Local Ordinance, or any Rule or Regulation of the State Revenue Commissioner, or any Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the last 12 months preceding the date of the application, or, o The following violation(s) of Georgia Law, Federal Law, Local Ordinance, or Rule or Regulation of the State Revenue Commissioner, or Rule or Regulation of the City of Tybee Island or Chatham County have been adjudicated against this business within the 12 months preceding the date of the application: m/ I have read the South End Policies and Procedures and will abide by said South End Policies and Procedures at all times during the term of the Sidewalk Cafe or Merchandise Display Permit. Notarized Signature: Printed Name: ► bt oL M D C A:� Y1 '5 t STATE OF GEORGIA COUNTY OF CHATHAM Date: 13 \\V-4 The fbregoyng instrument was acknowledged before me this 11 day of 0-Ci yN -r , 20 a _, by t LO; it r -D>. G k,� v1.5 b r1 who is personally known to me or who has produced identification. Signature o - Notafy Public My Commission expires: HAN, Page 2 of 6 ig 102. OFFICIAL SEAL MEGAN P BRIDGES Notary Public, Georgia CHATHAM COUNTY My Commis ion Expires MAYI c1 20 12/14/2012 Notarized signature: INDEMNIFICATION AGREEMENT (RELEASE AND HOLD HARMLESS AGREEMENT) This Indemnification, Release and Hold Harmless Agreement is made this 17 day of Jain .rU , 20 a,9-, , by ► �� ► �Y\ C. ► n 5 (7 n ("APPLICANT") for the benefit of the City Tybee Island, Georgia ("CITY"). When referred to herein, the CITY means the Planning and Zoning Manager, the municipality, its City Council, and each member thereof, and its officers, employees, advisory board members and representatives. WHEREAS, the APPLICANT is the owner or lessee of the property located at Island, Georgia; and, WHEREAS, the APPLICANT has applied for a Sidewalk Cafe or Merchandise Display Permit for the temporary use of the sidewalk area abutting the property described above pursuant to City Codes, ordinances, and policies and is required thereby to indemnify, defend and hold and save the CITY harmless for its use of the public right-of-way (hereinafter collectively the "PROPERTY"); and, WHEREAS, the APPLICANT is authorized to and has obtained all necessary approvals for this Agreement, NOW, THEREFORE, in consideration of the CITY allowing the APPLICANT to use the public right-of-way for its Sidewalk Cafe or Merchandise Display the APPLICANT agrees as follows: 1. The above recitals are true, and correct and are incorporated herein by reference, 2. The APPLICANT agrees to indemnify and hold and save the CITY harmless from any and all damages, loss or liability occurring by reason of any injury of any person or property which may occur as a result or consequence of the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. APPLICANT will, at their own cost and expense, defend and protect the CITY against any and all such suits, claims or demands which may be claimed to have arisen as a result or consequence of or in connection with the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them or occasioned by an act or omission, neglect, or wrongdoing of the APPLICANT or their family, officers, agents, representative, guests, employees, invitees, or persons contracting with either or any of them. Notwithstanding the foregoing, this should not be construed so as to require the applicant or anyone else to indemnify the CITY for claims arising from the sole negligence of the CITY, its agents, employees, or officers. 3. The APPLICANT does hereby remise, release, satisfy, quit claim, and forever discharge the CITY from any and all actions, suits, claims or demands that they ever had, now has, or may have in the future against the CITY as a result of the granting of the Sidewalk Cafe/Merchandise Display Permit or because of the use of the PROPERTY by the APPLICANT or their family, officers, agents, representatives, guests, employees, invitees, or persons contracting with either or any of them. 4. The APPLICANT will maintain liability or other insurance as required by City codes, ordinances, and policies which shall name the CITY as an additional insured and for which the CITY will be given a current certificate. Said liability or other insurance shall provide coverage for any suit or claim arising from the issuance of the Sidewalk Cafe or Merchandise Display Permit or the use of the PROPERTY by the APPLICANT. 5. The terms of this Indemnification Agreement shall be binding upon and inure to the benefit of the parties and their heirs, legal representatives, successor and assigns. Printed name: lij ; Q�ann (--b'G ►Y.SOY1 Date: IK� STATE OF GEORGIA COUNTY,QF CHATHAM f#t The .fo►-eQoing instrument was acknowledged before me this day of -Tcor\LA, p►,r , 20 , by t, a \\ ; G_l1r1 iG .i IN5 on who is personally known to me or who has produced i lentification. SignatutetwitA )V0') ure ofNotary Public My Commissign expires: V'ti o, 1. 4 , L O - Page 3 of 6 OFFICIAL SEAL MEGAN P BRIDGES Notary Public, Georgia CHATHAM COUNTY My CommissionF,x_pares MAYVI, 2< 12/14/2012 A�c>�a® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 08/30/2021 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the po icy, 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 Sterling Seacrest Pritchard P 0 Box 8004 Savannah GA 31402-8004 CONTACT Susan White NAME: (A/C, Ext): (912) 544-1900 AX No): (912) 544-1901 E-MAIL swhite@sspins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Cincinnati Specialty Underwriters Ins. Co. 13037 INSURED Wet Wllie's 11706 Mercy Boulevard Building 1 Savannah GA 31419 INSURER B : Acceptance Indemnity Insurance Co 20010 INSURER C : Zenith Insurance Company INSURER D : INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 21-22 COI • ------- -- -._._---- 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 LTR TYPE OF INSURANCE ADDL INSD SUER" WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CSU0133596 09/01/2021 09/01/2022 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 0 PERSONAL BADVINJURY $ 1,000,000 GEN'LAGGREGATE P POLICY OTHER: LIMIT APPLIES PRO JECT X PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG 2,000,000 $ $ A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY X SCHEDULED AUTOS NON -OWNED AUTOS ONLY CSU0133596 09/01/2021 09/01/2022 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILYINJURY(Peraccident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE EMM000039901 09/01/2021 09/01/2022 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED X RETENTION $ 0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N Y NIA M1057912 10/01/2021 10/01/2022 X PER STATUTE ER E.L. EACH ACCIDENT $ •500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 A Liquor Liability CSU0133596 09/01/2021 09/01/2022 Ea. Common Cause Aggregate $1,000,000 $2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Tybee Island is named as additional insured with respect to general liability as required by written contract. LDER City of Tybee Island 403 Butler Avenue Tybee Island GA 31328 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2015 ACORD CORPORATION. All rights re ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Additional Named Insureds Other Named Insureds Beaufort Wet Willie's, LLC D/B/A Wet Willie's Additional Named Insured Wet Willie's, Inc dba River Street Wet Willie's Additional Named Insured Memphis Wet Willie's, Inc. dba Memphis Wet Willie's Additional Named Insured South Beach Wet Willie's, Inc. dba South Beach Wet Willie's Additional Named Insured Wet Willie's Management Corp Additional Named Insured Columbia Wet Willie's, Inc. dba Columbia Wet Willie's Additional Named Insured Wet Willie's Franchise Corp. Additional Named Insured WW Resorts-ACY, LLC Additional Named Insured Myrtle Beach Wet Willie's, LLC dba Myrtle Beach Wet Willie's Additional Named Insured Tybee Island Wet Willie's, LLC dba Tybee Wet Willie's Additional Named Insured Wet Willie's City Market, LLC dba City Market Wet Willie's Additional Named Insured Mobile Wet Willie's, LLC Additional Named Insured OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC . Iv-- lE'V PAINETED ; u0. ;1.1t;,'=RED A:MING s New Flo or Pla n SC E: Y/a" = i+- n —NEW PAINETEO L+ :,. LOJVERE0 -:: O NG 1I1' PA,C1P ED AL:iI, . LOUVERED A ANC —PIE" PAINEMED ALUM. LOUVERED M' 4ING !s DOOR AND FRAME SCHEDULE DOOR FRAME S1ZF MAIL EL GLAZING fl� SIZE "" NIA1- EL DETAILS OPENING PROTEC114N LT.NER4L NOTES HEAD J :E 5111 EASING - - - - - - - - - PR FED VERITY - - 1/2 -, _ N5E L0 'EERED PR FIELD YEW' - - 1/2' - - - - - - -" FALSE LOWERED PR FIEU) VERIFY - - 1/2 - - - - - - - FALSE LOWERED PR FIELD VERIFY - 1/2 - - - - - - FALSE LOOM) 3'_.O" X 7°-G- RCM - - AM - - - - 3'-0" X r-0" SCWD - - H!d - - - - - - 3.-0" X r-0'- -.—,..-W —.—,..-- H.m. INSCLATe"D - - - `0A - - - - - TO BE STAIN GRADE 111/160 DOOR ALL SIDES [TO INCLUDE TOP & BOTTOM] DORS a FRAMES TO BE PAINTED TO .A1CF1 ADL'ACENT WALLS. ROOM FI NISH SC HE[ Na dat{E FLOOR BASE WALLS F N 3W3 5/3' G SUM WAIL B. PRIMED CHU ..� .. _ 105 8AR 0 0 • • 06 R 0 0 • 107 R/R 0 0 • 108 KIICNEN 0 0 • 109 TTORAGE ��- �1 �� 1 Ii01E1 1. ALL FINAL COLOR S0 ..EC11000 TO 8E ALOE AND APPROVED BY OWNER AND ARCHITECT