AgriTourism Self-Inspection "PLEASE PRINT CLEARLY"

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Godwin Singleton
5 years ago
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1 Name (Business Owner or Manager) Business Name Address Street / City / Prov / Postal Code Risk Location (if other than above) NOTE: Operational Requirement Forms must be adhered to and signed prior to the binding of coverage under this Program. General Information: 1. Operating Hours Operating Season 2. Business hours are posted and adhered to ( by appointment only is acceptable) Yes No 3. Areas accessible to guests are well maintained and free from hazards Yes No 4. Clean toilet and hand washing facilities are available to customers Yes No 5. Separate hand washing facilities with soap and clean paper towels are available to customers if you operate a Petting Zoo, U-Pick or U-Press Yes No 6. Access road or driveway is safe and well maintained Yes No 7. Safe and adequate parking is provided for customers Yes No 8. Property has adequate lighting. Yes No Alcohol Sale, Service or Consumption Is alcohol sold, served or consumed Yes No If no, go to next section. Type of Liquor License: Permanent License Temporary Permit for Events Alcohol is served only with food Yes No Amusement Areas (including Playgrounds / Haunted Houses Is there any existing or planned Playground Equipment Yes No Is there an existing or planned Haunted House Yes No Is there any existing or planned Mechanical Rides Yes No Signs are posted stating parents are responsible for the supervision of their children Yes No Fully describe any other Amusement activities on the premise: ( NOTE: Photographs MUST BE PROVIDED for all items indicated above ) Animal Riding (Horse / Pony) A Release and Acknowledgement Form will be signed by each and every rider Yes No All employees or independent contractors involved will be fully informed of the Operational Requirements Yes No If an independent contractor is used, they have provided you with evidence of valid insurance with you added as an additional insured Yes No Crop Maze Any added features to the maze are inspected with any deficiencies repaired or replaced Yes No Fully describe any special features or attractions added to the maze: Alberta Farm Fresh Page 1 of 5 ( )

2 (Page Two) Entertainment (Live and / or Dances) Fully describe the types of Live Entertainment anticipated over the next 12 months: Equipment / Items Provided or Rented to the Public A Release and Acknowledgement will be signed by all participants Yes No Indicate all types of equipment available to or rented to the Public: Type Quantity Available Type Quantity Available Bicycle/Tricycle/Pedal Cart Motorcycle/Scooter Mountain Bikes Downhill Skis Boats Cross Country Skis Canoes/Kayaks Snowshoes Fishing Gear Snowmobiles Horses All Terrain Vehicles Fully describe any other equipment not listed above that is available to or rented to the public: NOTE: Scale of water difficulty must be very easy with few riffles, small waves and few obstructions Firework Displays Fireworks will only be handled by licensed pyrotechnician(s) operating under a permit for the location, dates and times for the display Yes No The pyrotechnician will provide evidence of valid insurance with you added as an additional insured Yes No Evidence of insurance provided by the pyrotechnician will be submitted to Capri prior to the event Yes No Guest Ranch / Working Vacation A Release and Acknowledgement will be signed by all participants Yes No Fully describe the activities available / provided / expected of all participants: NOTE: If animals are provided or rented to participants, make sure you have completed the Animal Riding section Alberta Farm Fresh Page 2 of 5 ( )

3 (Page Three) Petting Zoo Hand washing facilities are readily available for public use Yes No Soap and clean paper towels are available at the hand washing facility Yes No Indicate all the type of animals on display at the Petting Zoo: Horse Cattle Swine Chicken Donkey Bison Dog Turkey Mule Elk Cat Goose Llama Deer Rabbit Duck Alpaca Goat Sheep Birds Fully describe any other animals involved that are not mentioned above: Processed Food or Beverages (processed on premise) What food and / or beverage is being processed on the premises: Restaurant Any frying (deep fat or other) done on the premises Yes No If yes, are all frying areas protected by an automatic fire suppression system Yes No Is the automatic fire suppression system inspected annually Yes No Date of last inspection was (mm/dd/yyyy) Washrooms are maintained in an above average state of cleanliness Yes No Washroom door locks are operational and in proper working order Yes No Washroom(s) are adequately stocked with soap, paper towels and toilet paper Yes No Waste receptacles are emptied on a regular basis Yes No Kitchen and washroom lighting is adequate and in good order Yes No Alberta Farm Fresh Page 3 of 5 ( )

4 (Page Four) Teamster Type Rides NOTE: All wagons, sleighs, buggies, carts, carriages and non-motorized conveyances are hereafter referred to as vehicle or vehicles Vehicles are operated by an employed driver or independent contractor at all times Yes No All passengers will be assisted in and out of the vehicle Yes No All employees or independent contractors involved will be fully informed of the policy requirements and will agree to enforce them Yes No If an independent contractor is used, they will provide evidence of valid insurance with you added as Yes No an additional insured U-Pick Operations NOTE: Includes Christmas Tree harvesting by the public Is any equipment provided to the public Yes No If yes, indicate all equipment provided: Hand Saws Chain Saws Ladders Shears Other Fully describe any other items provided to the public: U-Press Operations Do you press the fruit for the public Yes No What type of fruit is being pressed: Apples Cherries Grapes Pears Other Waterborne or Adjacent to Water Activities Is swimming allowed on the premises Yes No NOTE: If any equipment is provided or rented to the public, make sure you have completed the Equipment Provided or Rented section. Wild Life Park Indicate all the type of animals on display (animals behind fences; no petting allowed): Horse Cattle Swine Chicken Donkey Bison Dog Turkey Mule Elk Cat Goose Llama Deer Rabbit Duck Alpaca Goat Sheep Birds Fully describe any other animals involved that are not mentioned above: Alberta Farm Fresh Page 4 of 5 ( )

5 (Page Five) General Safety and Policy Requirements for All Operations 1. Accident Report Forms will be completed for all known incidents. 2. A qualified staff person is always on site with a valid First Aid Certificate and CPR. 3. Some type of camera will be available to photograph accident scenes. 4. A safe environment is maintained for the public. 5. Hazards are identified and rectified to minimize slipping, tripping and falling. 6. Hazards are promptly reported, removed, repaired or replaced. 7. A staff person is assigned responsibility for regular safety inspections. 8. Maintenance of all equipment is done on a regular basis. 9. Equipment is inspected before and after use by the public. 10. Operational Requirements must be signed for the following operations: Amusement Areas (including Playgrounds / Haunted Houses Animal Rides (Horse / Pony) Crop Maze Entertainment (Live and / or Danes) Equipment / Items Provided or Rented to the Public Firework Displays Guest Ranch / Working Vacation Petting Zoo Processed Food or Beverages Restaurant Teamster Type Rides U-Pick Operations U-Press Operations Waterborne or Adjacent to Water Activities Wild Life Park 11. Release and Acknowledgement Forms will be signed by every participant for the following operations: Animal Rides (Horse / Pony) Equipment / Items Provided or Rented to the Public Guest Ranch / Working Vacation U-Pick Operations (where tools or equipment for harvesting is provided) Waterborne or Adjacent to Water Activities I / We declare that the information contained in this Self-Inspection is accurate and that no material information has been withheld. Signature Date Signed Alberta Farm Fresh Page 5 of 5 ( )

Ontario Campground Owners Insurance Application. Name of Applicant: Principal(s) Name: Mailing Address: Location Address: Contact Name: Telephone:

Ontario Campground Owners Insurance Application Name of Applicant: Principal(s) Name: Mailing Address: Location Address: Contact Name: Telephone: Web-site Address: Loss Payee(s): Description of All Operations: