Cossio Insurance Agency Family Entertainment Centers
Activity 2
NOTE: Remember not to hit your back button or your refresh button so that you do not
accidentally erase or wipe out any type of information that you have typed in.
Please click on an operation type from the list. Then answer the questions inside each operations. After
completely answering the questions, you may click on a new type of operation to begin completing new sets of questions.
Coin Operated Rides
Annual sales:
$
How many do you have?
Describe:
Driving Ranges
Annual sales:
$
No. of stalls:
Partition between stalls?
Yes
No
Food Operations
Annual sales:
$
Do you have concessions?
Yes
No
Cooked on premises?
Yes
No
Is deep fryer grill on premises?
Yes
No
Prepackaged?
Yes
No
Alcoholic Beverages?
Yes
No
Do you have an auto. extinguishing system over deep fat fryers, grills, & stoves?
Yes
No
How often are hood/ducts cleaned:
Who cleans it?
Insured
Subcontractor
If by sub-contractor, how often are they serviced?
Date last serviced:
Cen. station fire alarm?
Yes
No
Cen. station burglar alarm?
Yes
No
Surveillance cameras?
Yes
No
Does the applicant have Automated External Defibrillator(s) AED?
Yes
No
Are staff members trained to use AED?
Yes
No
Do you have backup emergency lighting and/or emergency generators in the event of a power failure?
Yes
No
Do you have an emergency evacuation plan?
Yes
No
Please click on the browse button to upload your emergency plan.
Evacuation procedures and floor plans posted?
Yes
No
Are parking lots well lit?
Yes
No
Security patrolled?
Yes
No
Do you provide live entertainment?
Yes
No
Describe and how often you provide live entertainment:
Go-karts
Annual sales:
$
How many?
No. of tracks:
Max. speed (mph):
Indoor/Outdoor?
Indoor
Outdoor
No. of attendants:
Max. number on track any one time:
Gas or Electric?
Gas
Electric
Minimum age:
Minimum height:
Seat belts required?
Yes
No
Operator cut off system?
Yes
No
Equipment with governors to control speed?
Yes
No
Outdoor tracks fenced?
Yes
No
Bumper guards or roll bars?
Yes
No
Fences meet ASTM F-24 requirements?
Yes
No
Track rules clearly and prominently posted?
Yes
No
Track length:
Type of track:
Slick
Dry
Perimeter barrier type:
No. of single carts:
No. of double carts:
Go-kart manufacturer:
No. of karts on track at once:
Type of seat belt:
Helmets required:
Yes
No
Safety Signs?
Yes
No
Racing allowed?
Yes
No
If racing is allowed, describe circumstances:
Gas stored away from track?
Yes
No
How far is refuel area from track?
Spectators clearly separated from track?
Yes
No
Any patrons given waivers to sign?
Yes
No
Please click on the browse button to upload your waiver.
Gift/Pro-Shops
Annual sales:
$
Please make sure that you have completed everything to the best of your knowledge before going to the next page.