APPENDIX E
MANUFACTURED HOUSING COMMUNITIES
RESTAURANT SUPPLEMENTAL QUESTIONNAIRE

Required For Contact Purposes
Name: E-Mail Address :

Insured: Policy #:

Address: Owner of Restaurant:

City: State: Zip:

Date Completed:

Section A-Equipment: Indicate, which of the following apply, and the number of each:


Ranges Ovens Deep Fryers Grills Broilers Griddles

Are deep fryers controlled by 475-degree high-limit thermostat?
Yes No

Is the distance between other cooking surfaces and the deep fryer a minimum of 16 inches?
Yes No

Are all combustible walls greater than 18 inches from the nearest cooking unit?
Yes No

Section B – Vents, Hoods, & Ducts: Provide the following information; not necessary details in the narrative:


Are all cooking units covered by hoods and vents?
Yes No

Are vents protected by filters or grease extractor system?
Yes No

Are hoods vented top the outside ducts?
Yes No

Do vents extend into or through roof space or other concealed areas?
Yes No

Are hoods vented at least 18 inches from combustible material or otherwise suitably protected?
Yes No

Are adequate clean-out openings provided?
Yes No

Is grease build-up noted anywhere on the exhaust system?
Yes No

Is there a contract with a commercial firm to clean and service the exhaust system?
Yes No

Does the cleaning schedule appear adequate?
Yes No

Are wiring and lighting protected from grease build-up?
Yes No

How often is the hood and duct system cleaned?
By whom?

Restaurant Supplemental Questionnaire

Section C – Protection: Provide the following information, note necessary details in the narrative:


Is the automatic extinguishing system provided in the hood and duct?
Yes No
Manufacturer:

Does the system cover all cooking surfaces?
Yes No

Is the automatic fuel shut-off provided?
Yes No

Is an accessible means of manual activation of the extinguishing system provided?
Yes No

Are separate temperature high-limit controls provided on the deep fat fryers?
Yes No

Are proper portable fire extinguishers provided in the kitchen?
Yes No

Is the maintenance contract maintained on the extinguishing system?
Yes No

By whom?

How often is the extinguishing system serviced?
By whom?

______________________________________________________________________________________________

Park Owner ___________________________________________ Date ________________________

Restaurant Owner ______________________________________ Date _________________________

Comments:

COPY OF CERTIFICATE OF INSURANCE SHOWING OUR INSURED, AS AN ADDITIONAL INSURED MUST BE ATTACHED TO QUESTIONNAIRE

This questionnaire is not intended as loss control services or a replacement for such service.