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Restaurant Program Supplemental Questionnaire
Restaurant Program Supplemental Questionnaire
Name
*
Email
*
Phone
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Hours of Operation Dining Area:
Hours of operation bar area (if different than dining):
Is food served until within at least one hour of closing time (including bar closing time?)
Yes
No
Total number of seats in Dining
Total number of seats in Bar/Lounge
Does the restaurant close for more than 30 consecutive days (i.e. seasonal business?)
Yes
No
Check restaurant type that best describes this operation:
Counter service, takeout only, no seating at restaurant
Order at counter with limited or no table service, with seating in restaurant
Full table service with wait staff taking customer orders at the table
How many years has restaurant operated at this location?
If this is a new restaurant opening, attach a brief resume’ for the full-time manager and a business plan.
Max. file size: 59 MB.
If restaurant has been open less than 3 years, does the full-time manager have at least 5 years of restaurant management experience in the area?
Yes
No
If restaurant has been open less than 3 years, does the head chef have at least 5 years of restaurant management experience in the area?
Yes
No
Complete for Property Coverage
Types of kitchen appliances (check all that apply):
Select All
Deep Fryers
Broilers
Grills
Ranges
Ovens
Other
Any table-side cooking? (describe)
Is the ansul system UL300 compliant?
Yes
No
Automatic fire extinguishing system provides surface protection for all cooking surfaces?
Yes
No
Automatic Extinguishing System Serviced No Less Than Every 6 Months:
Yes
No
Name of service firm:
Service Interval:
Do metal hoods and ducts cover all cooking surfaces?
Yes
No
Hoods equipped with removable filters or grease extractors vented to outside of building?
Yes
No
All cooking or heating devices installed with minimum 18 inches safe clearances to combustible walls, ceilings, etc?
Yes
No
Manual pull for extinguisher system readily accessible and clearly identified?
Yes
No
All gas fired cooking equipment and electric deep fat fryers equipped with automatic fuel shut off?
Yes
No
All deep fat fryers equipped with thermostat with automatic fuel shutoff if temperature exceeds 475°?
Yes
No
Number of portable fire extinguishers in kitchen area
Central station burglar alarm?
Yes
No
Central station fire alarm?
Yes
No
Hoods and ducts cleaned as necessary by outside firm under contract?
Yes
No
Name of Firm:
Cleaning Schedule:
Monthly
Quarterly
Semi-Annual
Is refrigeration/freezing equipment under a maintenance agreement?
Yes
No
Is the building listed on the National or Local Historic Registry?
Yes
No
Is the actual age of the building greater than 20 years old?
Yes
No
If yes, describe updates to the roof, electrical, HVAC and plumbing systems including year completed:
Is there a wood burning stove or fireplace on premises?
Yes
No
Complete for General Liability Coverage
Number of FT Employees:
Number of PT Employees:
On Premises Food $
On Premises Liquor $
Off-Premises Catering $
Other (explain) $
On Premises Food $
On Premises Liquor $
Off-Premises Catering $
Other (explain) $
Describe type(s) of off-premises catering provided, if any.
Does the restaurant allow dancing?
Yes
No
If yes, is there a dance floor?
Yes
No
Size in square feet:
Number of evenings/week with dancing?
Type of music:
Does the restaurant have live entertainment or a DJ?
Yes
No
If Yes, type of entertainment:
Does the restaurant have electronic games, TVs, billiards or other entertainment devices?
Yes
No
If yes, describe – number and type:
Does the restaurant have an indoor or outdoor playground?
Yes
No
Are floor transitions clearly marked?
Yes
No
Does the restaurant have an on-premises banquet facility?
Yes
No
If yes, annual banquet sales: ($)
What percentage of total banquet sales are weddings? (%)
Does the restaurant offer delivery service?
Yes
No
If yes, check all that apply:
By employees – on foot
By employees – on bicycle
By contract (outside) delivery service
By employees with personal autos
By employees with company autos
Delivery area (radius from restaurant in miles):
Does the restaurant sell food or condiments manufactured under its own label?
Yes
No
If yes, give annual sales and describe products:
Is the restaurant in compliance with ADA requirements?
Yes
No
Is the applicant aware of any present or past incident that may give rise to a data breach claim?
Yes
No
Has the applicant had data breach insurance coverage denied, canceled or non-renewed during the last three years?
Yes
No
If Yes, give details:
Does the applicant own a parking lot? (If “no,” skip the next 2 questions.)
Yes
No
If parking lot is not owned by applicant, is applicant responsible for maintenance of the parking lot?
Yes
No
If answer to both of the above questions is “no,” does applicant indemnify (through the lease agreement) the entity which owns or maintains the parking lot or will such entity be an insured under the applicant’s general liability insurance?
Yes
No
Does the restaurant offer valet parking? (If “no,” skip the next 4 questions.)
Yes
No
If yes, is valet parking performed by the restaurant’s employees?
Yes
No
If yes, does the restaurant check the driving records of valet parking attendants?
Yes
No
If you offer valet using an outside firm, does that firm have insurance coverage in force to cover liability arising out of valet parking including physical damage to customers’ autos?
Yes
No
If you use an outside valet firm, is the restaurant included as an insured under the firm’s garage and garage keepers insurance?
Yes
No
Customer Incident/Complaint Handling: (Check the appropriate description.)
Waitpersons are trained in proactive customer incident/complaint procedures management procedures
Customer incident/complaint handling is not discussed with wait staff.
Wait staff instructed to take passive response to customer incidents or complaints
Health Department Rating: (Check the latest applicable rating.)
“A” or equivalent grade
“B” or equivalent grade
“C” or equivalent grade
“D” or below
Complete for Liquor Liability Coverage
Liquor license type:
Beer & Wine
Full Liquor
Liquor liability limit:
$1 Mill
Other (Fill in below)
Other: $
Any special consumption promotions such as ladies night, 2 for 1’s, etc.?
Yes
No
If Yes, describe:
Do you serve any flaming drinks?
Yes
No
If Yes, describe:
Do you dispense or provide alcoholic beverages for off-premises events?
Yes
No
Has applicant, any owner, partner, officer of licensee ever had a liquor license revoked or suspended?
Yes
No
If Yes, describe:
Have the authorities been called to your premises for any reason during the past five years?
Yes
No
If Yes, describe:
Is training provided for all servers and bartenders in the responsible service, sale and consumption of alcohol using an outside services such as TIPS?
Yes
No
If Yes, give name of program and frequency of training:
Are customers served without checking ID?
Yes
No
Does applicant have “bouncers” or door checkers?
Yes
No
Does applicant currently carry liquor liability insurance?
Yes
No
Has the applicant had liquor liability insurance coverage denied, canceled or non-renewed during the last three years?
Yes
No
If Yes, give details:
Name
This field is for validation purposes and should be left unchanged.
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