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COOLER FREEZER C00
12 13 12
CORRIDO
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45
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19 MECH. RM.
❑35/ 36 19
21 14 ❑23✓ 48 8 23❑
44
34A 36 4 18
41
21 El❑ 34 NO. EQUIPMENT NAME DIMENSIONS
24 33 36 40 HALL B10 GLASS STOAGE TABLE 24"X24"
22 ❑ 32 48 8 KITCHEN 15 B11 STANDARD BAR SINK 59"X17 3/4"
11 0 812 JOCKEY BOX 35"X17 1/2"
813 MUG CHILLER 24"X26 1/2"
22 25 31 37 39 B14 GLASS WASHER ECOLAB MODEL 24"X24"
615 GLASS STORAGE TABLE 24"X24"
B16 TRASH CAN FIXED SIZE 10"X27" E ' ..
E 28 30 36 16 WE 17S B17 JOCKEY BOX- 36X18 1/2
22 A
STORAGE UNIT W DOORS 48X27
618 DRY /
20 26 29 3 B19 BACK BAR REFRIGERATOR 59X27
B20 WINE COOLER 30"X27"
B21 BACK BAR REFRIGERATOR 59"X27" -
22 Ek__�l6 22 4 822 KEG REFRIGERATOR 59"X27"
SERVING B23 CAPPUCCINO MACHINE 19 1/2X21"
10 B24 DRY STORAGE UNIT W DOORS 48"X27"
22 4 P10 EARTHSTONE PIZZA OWEN
P11 REFRIGERATOR SANDWICH UNIT OFFICE
OFFIC P12 PIZZA PREP TABLE 09
09 P13 STAINLESS PREP TABLE
P14 STORAGE TABLE W/ SHELVES CARPET
5 4 P15 HAND SINK
B ET 2 14. ICE MAKER, CUBE STYLE 42"X31 1/2"
15. SODA MACHINE
08 16. WORK TABLE 96"X24"
�r 17. NOT USED
4 4 4 4 4 18. NOT USED
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19. CAN RACK
DINING 2
06
20. MIXER 40 QUART 25 1/2"X25" C
4 4 4 21. STOCK SHELVING 60"°X37"
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EHS-106-Rev.06/01 INSPECTION REPORT STATE OF CONNECTICUT L144WTINE INSPECTION 0 REINSPECTION
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH 0 PREOPERATIONAL 0 OTHER
410 Capitol Avenue,MS#51 FDP,Hartford,CT 06134
NAME OF ESTABLISHMENT
ESTABLISHMENT ���fu.�J CLASS Four
STREET TOWN `/
ADDRESS �� 1YCt r► t��/ V 1 W Wffv
OWNER or INSPECTION ,L�^
OPERATOR DATE and TIME 3—
Based on an inspection this day,the items marked below identify the violations in operation or facilities which must be corrected by the date specified below.
SOURCES OF FOOD EQUIPMENT&UTENSILS:CLEANLINESS VERMIN CONTROL
1 Approved source,wholesome, 4 21 Preflushed,scraped,soaked and racked 42 Presence of insects/rodents 2
nonadulterated 22 Wash water clean,proper temperature 1 43 Outer openings protected against entrance of 1
2 Original container,properly labeled 1 23 Accurate thermometers provided,dish basket,If used insects/rodents
24 Sanitization rinse(hot water-chemical) 2
FOOD PROTECTION 25 Clean wiping cloths 1 FLOORS,WALLS&CEILINGS
3 Potentially hazardous food meets 4 26 Food-contact surfaces of utensils& 2 44 Floors:floor covering installed,
temperature requirements during storage, equipment clean constructed as required,good repair,clean
preparation,display,service,and
transportation 27 Nonfood-contact surfaces of utensils& 1 45 Floors,graded,drained as required 1
equipment clean 46 Floor,wall juncture covered
4 Adequate facilities to maintain product 2 28 Equipment/utensils,storage,handling 47 Mats removable,good repair,clean
temperature,thermometers provided
5 Potentially hazardous food properly thawed 2 48 Exterior walking,driving surfaces, 1
6 Unwrapped or potentially hazardous food 4 WATER SUPPLY good repair,clean
not reserved 29 Water source adequate,safe 4 49 Wails,ceilings attached,equipment properly 1
7 Food protected during storage,preparation, 30 Hot and cold water under pressure, 2 constructed,good repair,clean. Wall&ceiling
display,service&transportation 2 provided as required surfaces as required.
8 Food containers stored off floor 50 Dustless cleaning methods used, 1
SEWAGE DISPOSAL cleaning equipment properly stored
9 Handling of food minimized 2 31 Sewage disposal approved 4
10 Food dispensing utensils properly stored 1 32 Proper disposal of waste water 1 LIGHTING&VENTILATION
11 Toxic items properly stored,labeled,used 4 51 Adequate lighting provided as required 1
PLUMBING 52 Room free of steam,smoke odors 1
PERSONNEL 33 Location,installation,maintenance 1 53 Room&equipment hoods,ducts,vented as required
12 1 Personnel with infection restricted 4 34 No cross connection,back siphonage,backflow 4
DRESSING ROOMS&LOCKERS
CLEANLINESS OF PERSONNEL TOILET FACILITIES 54 Rooms adequate,clean,adequate lockers 1
13 Handwashing facilities provided, 4 35 Adequate,convenient,accessible,designed, 4 provided,facilities clean
personnel hands washed clean installed
14 Clean outer clothes,effective hair restraints 1 36 Toilet rooms enclosed with self-closing door 1
15 Good hygienic practices,smoking restricted 2 37 Proper fixtures provided,good repair,clean HOUSEKEEPING
55 1 Establishment and premises free of litter,no 1
EQUIPMENT&UTENSILS: DESIGN, HANDWASHING FACILITIES insect/rodent harborage,no unnecessary articles
CONSTRUCTION &INSTALLATION 38 Suitable hand cleaner and sanitary towels or 1 56 Complete separation from living/sleeping quarters 1
16 Food-contact surfaces designed,constructed, 2 approved hand drying devices provided, and laundry
maintained,installed,located tissue waste receptacles provided 57 Clean/soiled linens stored properly 1
17 Nonfood-contact surfaces designed, 1 58 No live birds,turtles,or other animals 1
constructed,maintained,installed,located GARBAGEIRUBBISH STORAGE&DISPOSAL (except guide dogs)
18 Single service articles,storage,dispensing 2 39 1 Approved containers,adequate number, 1
19 No reuse of single service article covered,rodent proof,clean NONSMOKING AREAS
20 Dishwashing facilities approved design,adequately J
40 Storage area/rooms,enclosures— 59 Seats 75 or more:Nonsmoking area provided, 3
constructed,maintained,installed,located properly constructed,clean sign(s)posted at entrance(s),smoking area
1 in by sign(s)
41 Garbage disposed of in an approved manner,
at approved frequency QUALIFIED FOOD OPERATOR
DEMERIT SCORE 60 Qualified Food Operator 3
L
3 2 1 RISK FACTOR VIOLATIONS IN RED 61 Designated alternate 2
62 Written documentation of training program 2
Signatu of Person in char
TOTAL RATING Date Corrections Due
f G11 0-1 f SI ED(Ins pec ( C
l ,0o
DESCRIBE DEFICIENCIES40N CONTINUATION SHEETS
Page_of_
INSPECTION REPORT STATE OF CONNECTICUT .
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
/3 � s .r'tiiFcr c�Ja'' 23
Inspection Form k Ranks:
2 � iltSlar�rr
A.
O k
r
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: �Ist-White-Health Department 2nd-Yellow-Owner/Manager
c\centinsfortn2.cn
i
STATE OF CONNECTICUT
DEPA.IZT'NIEIVT of coNsLuvwR moT cnm..
LIQUOR DIVISION
TO: THE DEPARTMENT OF LIQUOR CONTROL
165 CAPITOL AVENUE
HARTFORD, CT 06106
I CERTIFY THAT Joseph D. M a r r e 11 o
NAME OF PERMITTEE.
NAME OF ESTABLISHMENT -
501 Evergreen Way
STREET
South Windsor
TOWN OF CITY
PATIO: Yes. ..r. No
COMPLIED WITH THE REQUIREMENTS OF THE STATE PUBLIC HEALTH CODE ON PLACES
DISPENSING FOOD AND BEVERAGES AT THE TIME OF INSPECTION.
DATE• �� _�jE, (/C•
SIGNATURE Off DIRECTOR OF HEALTH
OR HIS AGENT
l
4 •
P-14
Hand Sink
P-10
P-13
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P-11
P-12
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COOLER FREEZER
12 13
CORRIDO
14
45
36
F-135
.�2 Hand Sink
21 Hand Sink 38
,4
I 34A 36 41
21 � 34
-99' -111 40
24 33 36 HALL
22 Hand Sink 32 38 KITCHEN 15
I H i 11 F39
22 253 31 37
22A 28L ® 30 36 16
20 EI
29 Q
22 15 16 22 4
SERVING
10
22 4
OFFIC
09
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ET 2
08
MARRELLO MANAGEMENT GROUP
MEMORANDUM
TO: FROM:
Bob Peft& Joe Marrello
COMPANY: DATE:
Town of South WIndsor 9/15/2005
FAX NUMBER: TOTAL NO.OF PAGES INCLUDING COVER:
2
PHONE NUMBER: SENDER'S REFERENCE NUMBER:
RE: YOUR REFERENCE NUMBER
Bellias Italian Eatery
0 URGENT ❑FOR REVIEW 0 PLEASE COMMENT ❑PLEASE REPLY ❑PLEASE RECYCLE
This is the floor plan for the kitchen and bar layout for the BelWs Italian Eatery located in The Shops at
Evergreen Walk.
If there is anything else you might need please feel free to contact me at(518)218-1105 or(518) 858-
2773.
Thanks-Joe
210 WASHINGTON AVENUE EXTENSION
ALBANY, NEW YORK 12203
PHONE- 518-218-1105 FAX 218-1703
EHS-106-Rev.06101 INSPECTION REPORT STATE OF CONNECTICUT 2-ROUTINE INSPECTION ❑ REINSPECTION
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH ❑ PREOPERATIONAL ❑ OTHER
410 Capitol Avenue,MS#51 FDP,Hartford,CT 06134
NAME ', _//� ESTABLISHMENT
ESTABLISHMENT
CLASS
i/�U
STREET TOWN /
ADDRESS U( vr/�^k rvt GCS ay ,S,C 4,j utDJv�
OWNER or INSPECTION
OPERATOR DATE and TIME
Based on an inspection this day,the items marked below identify the violations in operation or facilities which must be corrected by the date specified below.
SOURCES OF FOOD EQUIPMENT&UTENSILS:CLEANLINESS VERMIN CONTROL
1 Approved source,wholesome, 4 21 Preflushed,scraped,soaked and racked 42 Presence of insects/rodents 2
nonadulterated 22 Wash water clean,proper temperature 1 43 Outer openings protected against entrance of 1
2 Original container,properly labeled 1 23 Accurate thermometers provided,dish basket,if used insects/rodents
24 Sanitization rinse(hot water-chemical) 2
FOOD PROTECTION 25 Clean wiping cloths 1 FLOORS,WALLS&CEILINGS
3 Potentially hazardous food meets 4 26 Food-contact surfaces of utensils& 2 4 Floors:floor covering installed,
temperature requirements during storage, equipment clean constructed as required,good repair,clean
preparation,display,service,and
transportation onfood-contact surfaces of utensils& UY 45 Floors,graded,drained as required
equipment clean 46 Floor,wall juncture covered 011
4 Adequate facilities to maintain product 2 28 Equipmentfutensils,storage,handling 1 47 Mats removable,good repair,clean
temperature,thermometers provided
5 Potentially hazardous food properly thawed 2 48 Exterior walking,driving surfaces, 1
6 Unwrapped or potentially hazardous food 4 WATER SUPPLY good repair,clean
not reserved 29 Water source adequate,safe 4 -49 Walls,ceilings attached,equipment properly 77
7 Food protected during storage,preparation, 30 Hot and cold water under pressure, 2 constructed,good repair,clean. Wall&ceiling
display,service&transportation 2 provided as required surfaces as required.
8 Food containers stored off floor 50 1 Dustless cleaning methods used, 1
SEWAGE DISPOSAL cleaning equipment properly stored
9 Handling of food minimized 2 31 Sewage disposal approved 4
10 Food dispensing utensils properly stored 1 32 Proper disposal of wastewater 1 LIGHTING&VENTILATION
11 Toxic items properly stored,labeled,used 4 51 Adequate lighting provided as required 1
PLUMBING 52 Room free of steam,smoke odors 1
PERSONNEL 33 Location,installation,maintenance 1 53 Room&equipment hoods,ducts,vented as required
12 1 Personnel with infection restricted 4 34 No cross connection,back siphonage,backfiow 4
DRESSING ROOMS&LOCKERS
CLEANLINESS OF PERSONNEL TOILET FACILITIES 54 Rooms adequate,clean,adequate lockers 1
13 Handwashing facilities provided, 4 35 Adequate,convenient,accessible,designed, 4 provided,facilities clean
personnel hands washed clean installed
14 Clean outer clothes,effective hair restraints 1 36 Toilet rooms enclosed with self-closing door 1
15 Good hygienic practices,smoking restricted 2 37 Proper fixtures provided,good repair,clean HOUSEKEEPING
55 Establishment and premises free of litter,no 1
EQUIPMENT&UTENSILS: DESIGN, HANDWASHING FACILITIES insect/rodent harborage,no unnecessary articles
CONSTRUCTION &INSTALLATION 38 Suitable hand cleaner and sanitary towels or 1 56 Complete separation from living/sleeping quarters 1
16 Food-contact surfaces designed,constructed, 2 approved hand drying devices provided, and laundry
maintained,installed,located tissue waste receptacles provided 57 Clean/soiled linens stored properly 1
17 Nonfood-contact surfaces designed, 1 58 No live birds,turtles,or other animals 1
constructed,maintained,installed,located GARBAGEIRUBBISH STORAGE&DISPOSAL I(except guide dogs)
18 Single service articles,storage,dispensing 2 39 Approved containers,adequate number, 1
19 No reuse of single service article covered,rodent proof,clean NONSMOKING AREAS
20 Dishwashing facilities approved design,adequately 2 40 Storage area/rooms,enclosures— '59 Seats 75 or more:Nonsmoking area provided, 3
constructed,maintained,installed,located properly constructed,clean sign(s)posted at entrance(s),smoking area
1 indicated by sign(s)
41 Garbage disposed of in an approved manner,
at approved frequency QUALIFIED FOOD OPERATOR
DEMERIT SCORE F62
Qualified Food Operator 3
L
3 2 1 RISK FACTOR VIOLATIONS IN RED Designated alternate 2
Written documentation of training program 2
Signature Person in charge
TOTAL RATING Date Corrections Due lz'�, Fk I
9-7 a f 1%*&1 al SIGNED Jpector) /,�
0 Y r'(j/` V�,
DESCRIBE DEFICIENCIES ON C NTINUATION SHEETS
Page_of_
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
Impomm Foam M Remwks:
1A s>:
INITIAL(INSPECTOR) v. INITIAL(PERSON IN CHARGE)
Distribution: 1 st-White-Health Department 2nd-Yellow-Owner/Manager
c:katinsformIcn
19. CAN RACK
DINING 2
06
4 4 4 4 20. MIXER 40 QUART 25 1/2"X25"
21. STOCK SHELVING 60""X37"
22. WORK TABLE W/ .48"X24"
4 O.H. SHELVING
23. HAND SINK 12"X12" CONC,
4 4 4 4 24. 2 COMPART, SINK 87"X27 3 4"
25. TWIN MIXER KETTLE 50.63"X27' D)
26. WIRE PAN RACK SHELF 20 3/8"X27 1'/8"
BANQUET 1 27. NOT USED
07 28. CONVECTION OVEN 38 1/4"X
29. MEDIUM RANGE (6) W/
4 OVERHEAD CHEES MELTER 36"X32"
30. GAS PASTA COOKER 20"X20"4 CONC.
4
31. MEDIUM RANGE (8) 48"X32"
32 GAS CHARBROLER 36"X35 1/2"
4 X., ,�. �.: Kra ��
S k
S.FRYER
20 3 39 4/5"
v.ASB RACK Sh-17 :_-
4 4 B22 'L' SHAPED
❑ B1 40. CONVEYOR DISH 44"X28"
0D 41. CLEAN DISH TABLE 60"X32"
® 42. THREE COMP. SINK 90"X27 1 Z' CONC.
DINING 1 616 1 43. OVERHEAD SHELVES /
72"X14"
05 ® 61 44. MICROWAVE W/ WALL SHELF
`n ® B1 45. UTILITY SINK DIN
24"X24"
4 4 ® 813 0 46. DRAWER WARMER Ec
47. NOT USED CAF
® B1 48. KITCHEN OVER SHELF W/HEAT LAMP
HALL ® BAR 9
4 4 02 ® DOE KEYED NOTES
Lo Lr) ® B1 / 9 O NOT USED
�/ O PROVIDE FIRE EXTINGUISHER CABINET
B ® P1S O 61 PROVIDE FIRE EXTINGUISHER MOUNTED ON WALL AT 3'-0" AFF
®
O PROVIDE FABRIC CURTAIN
B
VEST.
C
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FURNITUR E/EQUIPMENT PLAN
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112" THICK MARBLE
_R FREEZER THRESHOLD SET IN
Fl-31 HM FRAME DRYSET MORTAR
SEE SGHED. THIN 5ET W
GONGRETE 2" 2 CERAMIC, TILE d
VINYL REDUGER STRIP GONGRETE n�
SLAB
TILE FLOORING - d
MECH. RM.
19 THR-4 THR-2
ALUM. THRESHOLD SET
EPDXY FLOORING IN BED OF SEALANT
VINYL REDUGER STRIP (WIDTH OF THRESHOLD
TO MATCH WIDTH OF
TILE FLOORING DOOR FRAME)
O O N
FIN. FL.
THR-I
THR-3 NOTE: AT EXTERIOR DOORS
E$OXY°:
SERVII`IG :
Lij
CONC.
BANQUET 2
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ROOM FINISH SCHEDULE u
JG 2
I ROOM T WINDOW GENERAL REMARKS
N0. DESCRIPTION FLOOR BASE WALLS CEILING TRIM STooL
PE ALL COLOR SELECTIONS TO BE SELECTED R APPROVED BY OWNER FROM MANUFACTURER'S FULL RANCE cn
CI 07 VESTIBULE 12%12 CT B"Cf W-PUTPNT/GB CB/MCP SL
1'Pi. BUCK SLATE SMOOTH FINISH PROJECTED 1 2'W VERT.BASE 12'H
BANQUET 1 02 HALL 12X12 CT CT WD.WSC./GB SEE REMARKS/ WO _ PARNJNE 1,BY USO- POLISHED CHROME
PST GB . O
Q7 03 BAR 12X12 CT 6'CT WD.WSC./CB SEE GREBMARK� WD _ PARALINE 1,BY USG-POLISHED CHROME ._
CARPETPNT 04 PIZZA 12xtz cr s'cr wD.WSCwsc./ca GB/ADP wD _
OS DINING 1 CPT 6"IND. WD.WSC./GB GB/ACP WD -
06 DINING 2 - CPT 6'WD. WD.WSC./GB GB/ACPL
_
07 BANQUET 1 CPT 6'WD, WD.WSC./GB GB/ACPWD
OB BANQUET 2 CPT 6"WD, wD.wSC./CB CB/ACPWD _
09 OFFICE CPT 4'E.B. GB PAT- GB/MCP -
EPDXY RESIN DE% 0 TEX CHEMNIERT'K" T 4'THICK
16 CLOSET 12X12 CT 6"CT GB ARP _
❑ 17 MEN'S 12X12 CT CT CT/GB GB/ACP - -
18 WOMEN'S 12X12 CT CT CT/GB GB/ACP - -
G 1 >00 19 MECHANICAL CONC. 4"E.B. GB PHI - -
LEG 5UPPORT5,
ET GOOK. W/EQUIP. I ENGINEERS APPROVAL
>00 I'XI' GT NOTES:
SYMBOLS
1.ALL W000 RECEIVE MAFACONY FRISH,UNLESS NOTED OTHERWISE
CONC. 2. PAINT ALL EXPOSED GYP.BD.WALLS,FASCIAS AND SOFFITS W/SHERWIN WILLIAMS(PAINT COVES WHITE)COLORS SELECTED BY OWNER ACP- ACOUSTICAL CEILING PANELS
>00 3.PROVIDE TRANSITION STRIP AT POINT OF FLASH FLOOR TYPE CHANGE- SEE DETAILS ABOVE CONC. -CONCRETE
>00 4.SEE PUN NOTES AND DETAILS FOR INTERIOR WALL CONSTRUCTION AND GYPSUM BOARD REOUIREL"IS CT - CERAMIC TILES -
>00 5.PROVIDE 3'-0"HIGH WOOD WAINSCOT(DESIGN AS INDICATED ON INT.ELEVATIONS)AT PERIMETER aF ALL ROOMS EXCEPT: GB - GYPSUM BOARD
KITCHEN,MEN'S h WOMEN'S ROOM AND MECHANICAL ROOM II
E.S. - EXPOSED STRUCTURE
HD - HARDENER
PNT- PAINT
RB - RUBBER BASE
SL - SLATE
STN- STONE
WD _ WOOD DATE:
WSC- WAINSCOT July, 2005
FRP - FIBERGLASS REINFORCED PANELS
DESIGNED BY:
ILL
Moriu5z Piechowicz
DRAWN BY:
KPB/MP
SCALE:
A5 NOTED
2 3 DRAWING NAME:
FLOOR FIN15H PLAN d
FURNIJEGUIP. PLAN
FLOOR FINISH PLAN DRAWING NUMBER:
1 SCALE:1/8"= 1'-0"
A03
- r
cc ?Or1 OL_ jl�cre�>ic�
't��riv C-
FENNER_,
Establishment: Date of Inspection: 2 -Pr
ddress: Owner or Operator:
ADDITIONAL FOUR POINT ITEMS
KEY: DNC [DOES NOT COMPLY]
6 1 Foods not re-served.
-Unwrapped foods not re-served 31 Sewage disposal approved.
-Potentially hazardous foods not re-served = -Operating as required
11 Toxic chemicals. 34 No cross connections,back siphonage,backflow
-Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for:
-Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines
-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks
-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35rdesnfed,properly
lities. Adequate,convenient,accessible,
-Water quality in compliance installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food: Original container,properly labeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
5 otentially hazardous food properlythawed 41 Garbage/rubbish disposed of in an approved manner,atapproved frequency
1 Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present
4 Food worker:Clean outer clothes,effective hair restraints 43 Outeropenings protected against entrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed, 5 ors graded,drained as required
located
<11 6loor,wall juncture covered
7 Nonfood-contact surfaces designed,constructed,maintained,
1 , Mats removable,good repair,clean
installed,located
18 Single service articles,storage,dispensing
8 Exterior walking,driving surfaces,good repair,clean
19 No reuse of single service article 49 ails,ceilings attached,equipment properly constructed,good
20 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored
Equipment&Utensils: Cleanliness 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean
2 Nonfood-contact surfaces of utensils&equipment clean
55 Establishment and premises free of litter,no insect/rodent harborage,
28 Equipment/utensils,stnrage,handling no unnecessary articles
32 Proper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Propertoiletfixturesprnvided,good repair,clean entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection
th spection:
IN P R: P R N I Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
i nature ` Sig na ure L
p/nt ame print name
`��( 40 1 cwp— DATE CORRECTIONS DUE:
J v
phone nu ti r title
Page 2 of 2 plus continuation pages Acused Inspection 1/2002
Establishment: Inspection Date: Z Time: msp Einsp
Address/City: Health Dept: •tocJ /r JOS �`— Class: 1 2 3 4
Based on an inspection this day,the items m rked DNC identify the violat ns in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C N/0 N/A DNC KEY: C[complies] N/0[not observed] N/A[not applicable]
3 DNC[does not comply] 0[other] RTE[ready-to-eat]
g (: to
�s A Food workers have no exposed infected lesions/burns
2
B Personnel with infection restricted
Ills,� hae , /A 4
C Communicable disease of worker reported to local health director
A Approved shellfish,finfish meat&poultry USDA approved 11" jndswast ed, . NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
0 E Handwashing at appropriate times
100 Rw
A Hot holding greater than or equal to 1400F. (whole beef/pork roasts 130e F.) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 450 F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing
D Proper re-heating 0
E Proper internal cooking/consumer advisory posted
0 A Approved sanitizeravailable/adequate concentration of sanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp
B Proper food thermometer for product
D Pro ersanitizinprocedure
C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food
0 Q
P IF a "to
1ffiMW5FFW=' A Cloths and/or sponges in good repair and clean
B Wiping cloths kept in sanitizer between uses
A Produce washed
B Raw meats not stored/prepared near ready-to-eat foods 71
C Food covered properly A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
F No pooling of eggs not cooked immediately 0
8 Food containers stored off the floor
0 lie
�' " = A Soap/paper towels/ drying device available
A No unnecessary handling RTE and/or cooked foods with bare hands V B
Dispenser(s)working: ❑Soap ❑Papertowel
B Minimize food handling,other than ready-to-eat,with bare hands 1AC Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated altemate],PHF[potentially hazardous food],FB[foodbome]
PHFs are hot held at: IF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork What diseases related to FB illness are you required to report t e local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness polic s the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases tot N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N I a language barrier between inspector&CFO? Y N If yes indicate language spoken
List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions: Name(print):
oling recorded? Y N *Obtain
the title of above person(circle all that apply):CFO DA Mgr Cook Owner FW
Is cooling monitored for time&temp? Y N Is the monitodnjObtain signature of the person who received the CFO responsibilities information at the time of the
Is there a produce washing policy? Y N ♦Describe at is washed and inspection:
where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
••� i I NJ EM WdJWJ 01I
NAME OF i ecNT DATE OF •
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OR"OVA, v"EM m —M
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INITIAL
(INSPECTOR)
�!� :,
Estabtishment: Date of Inspection: R' "
ddress: Owner or Operator:
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
-Unwrapped foods not re-served 4, 31 Sewage disposal approved.
-Potentially hazardous foods not re-served -Operating as required
11 Toxic chemicals. No cross connections,back siphonage,backflow
-Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for:
-Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines
-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks
-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food: Original container,properly labeled 40 Garbage/rubbish storagearea/rooms,enclosures-properly constructed,clean
otentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
10 ood dispensing utensils properly stored 42 Vermin Control: No insects/rodents present
TT Food worker:Clean outer clothes,effective hair restraints 43 Outer openings protected against entrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed, Floors graded,drained as required
located 6 Floor,wall juncture covered
17 onfood-contact surfaces designed,constructed,maintained, 7 Mats removable,good repair,clean
installed,located
8 Exterior walking,driving surfaces,good repair,clean
18 Single service articles,storage,dispensing
19 No reuse of single service article 9 Walls,ceilings attached,equipment properly constructed,good
repair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed,
maintained installed located 501 Dustless cleaning methods used,cleaning equipment properly stored
EEquipment&Utensils; Cleanliness 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
12NAccurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean '
7 onfood-contact surfaces of utensils&equipment clean
55 Establishment and premises tee of litter,no insect/rodent harborage,
Equipment/utensils,storage,handling no unnecessary articles
32 Proper disposal of wastewater 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 571 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection
-ThikIN P PER I H E: er Inspection:
Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
Z 001/ 1---N
sig re ignature
pant _ print n me Z7 & Ai— U_
^�
phone number IYYtI, / title DATE CORRECTIONS DU : /
Page 2 of 2 plus continuation p ges Focused Inspecti=1/2002
i
Establishment: Inspection Date: Time: �Class:
insp Einsp
ddress/City: Health Dept: le �ci'�.� 1 2 a
Based on an inspection this day,the iterfis marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS:Listing is not inclusive of all possible debitable items C Nfl N/A IDNC I KEY: C[complies] N/0[not observed] NIA[not applicable]
3 DNC[does not comply] 0[other] RTE[ready-to-eat]
y Nx
. A Food workers have no exposed infected lesions/burns
B Personnel with infection restricted
1 ! pv �'�i►tOtttfe,etadttE�r�ed Cr N/A 4` C Communicable disease of worker reported to local health director
A Approved shellfish,flnfish,meat&poultry USDA approved
B Food cans in good condition(not dented,rusty,bloated,leaking) � �� � � '' ' ti 0' I%K 4
A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulterated foods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature 000el 0 D Personnel hands washed,clean/Proper handwash procedure
E Handwashing at appropriate times
0
MON.
A Hot holding greater than or equal to 140 F. (Whole beef/pork roasts 130o F.) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 45o F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing 00,
D Proper re-heating --H 24,001
E Proper internal cooking/consumer advisory posted 11 1 1 F 1 0 a
0 7kpproved sanifizeravailable/adequate concentration ofsanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate ie C Adequate ❑dishwashersanitizer ❑final rinse temp
B Properfood thermometer for product
D Pro er sanitizing procedure
C Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
0
A Cloths and/or sponges in good repair and clean
A Produce washed
B Wiping cloths kept in sanitizer between uses 011
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard g Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
o pooling of eggs not cooked immediately 00, 0
8 tood containers stored off the floor
0
onomm� -`� � �` A Soap/paper towels I drying device available
A No unnecessary handling RTE and/or cooked foods with bare hands B
Dispenser(s)working: ❑Soap ❑Papertowel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)fordispensing food/ice 0
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodbome]
PHFs are hot held at: F. PHFs are cold held at: OF. Describe ill ne conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork What di ses related to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: I ere a written illness policy that requires the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases to the QFO? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N Iflf ves indicate language spoken
List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions: Name(print):
Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
Is cooling monitored for time&temp? Y N Is the monitoring of ce g recorded? Y N .Obtain signature of the person who received the QFO responsibilities information at the time of the
Is there a produce washing policy? Y N *Describe what' ashed and inspection:
where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
Establishment: Date of Inspection3 7 r-?Z) j
Address: Owner or Operator-
ADDITIONAL POUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served. 4 31 Sewage disposal approved.
-Unwrapped foods not re-served 4
-Potentially hazardous foods not re-served -Operating as required
11 Toxic chemicals. No cross connections,back siphonage,backflow
Proper type/installation/backflow prevention device/air gap for:
-Stored properly,labeled properly,used properly -Food equipment -Hose connections -Dish machines
-Sanitizer concentration not to exceed maximum permitted-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machinesProper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food:Original container,properly labeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
&0,Xod dispensing utensils properly stored 42 Vermin Control: No insects/rodents present
4 Food worker:Clean outer clothes,effective hair restraints 43 Outer openings protected against entrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean
od-contact surfaces designed,constructed,maintained,installed, 5 Floors graded,drained as required
located 6 Floor,wall juncture covered
7 Nonfood-contact surfaces designed,constructed,maintained, 7 Mats removable,good repair,clean
installed,located
1 8 Single service articles,storage,dispensing
Exterior walking,driving surfaces,good repair,clean
19 No reuse of single service article 9 Pas,ceilings attached,equipment properly constructed,good
20 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required
maintained installed located 50 Dustless cleaning methods used,cleaning equipment property stored
Equipment&Utensils: Cleanliness 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature IRooms&equipment hoods,ducts,vented as required
2 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean '
7)Nonfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodentharborage,
Equipment/utensils,storage,handling no unnecessary articles
32 Proper disposal of waste water 56 j Complete separation from living/sleeping quarters and laundry
3 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,orotheranimals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Propertoiletfixturesyrovided,good repair,clean entrance(s),smoking area indicated by sign(s)
39 1 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean tine Inspection ❑Reinspection ❑ Preoperational Inspection
Ot rInspection:
N T PERSON IN CHARGE: Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
t e signature
T_ )�Zk
print name print name l�
qqznt
phone number title
` � c�r�� DATE CORRECTIONS DUE: CCC
Page 2 of 2 plus continuation pages Focused Inspection 1/2002
i
Establishment: Inspection Date: d 7 Time: pins REinsp
Address/City: Health Dept: � /
P �'. l.� e N �� Class: 1 2
Based on an inspection this day,the itlfns marked DNC identify tht violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS:Listing is not inclusive of all possible debitable items C N/A DNC KEY: C[complies] NIO[not observed] NIA[not applicable]
F 3 DNC[does not comply] 0[other] RTE[ready-to-eat]
°D �r hateP .• 2 1 I rs 'I with"E�fec + r�tes ret:teil C 0 IUA 4
62 Written documentation of training program A Food workers have no exposed infected lesions/burns
2 B Personnel with infection restricted
1 Approved sotrrce,wholesome,nonadolterated C IYO N/A 4 C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved V 1 13 Handwashing faciild"provided,hands washed,clean' C 0'' NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking)
A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesomelnonadulterated foods/safe
B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
0
_ E Handwashing at appropriate times LV
NNW
I@
A I Hot holding greater than or equal to 140oF. (whole beeflpork roasts 130e F.) 00,
❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 450F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing 00,
D Proper re-heating 0
E Proper internal cooking/consumer advisory posted
0 A Approved sanitizeravailable/adequate concentration ofsanitizer
i 11,I m nt c B Food-contact surfaces and utensils used for potentially
' , hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp
B Proper food thermometer for product
L Proper sanitizin rocedure
C Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
0 0 t "' 1." ems, . t OfT a
t' spilay, enrtc6 an!trans pbrtatidn y A Cloths and/or sponges in good repair and clean
A Produce washed B Wiping cloths kept in sanitizer between uses
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly 1-1
Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard g Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
F No pooling of eggs not cooked immediately 0
8 Food containers stored off the floor
0
xr-
A _ No unnecessary handling RTE and/or cooked foods with bare hands A Soap I paper towels/ drying device available
B Minimize food handling,other than ready-to-eat,with bare hands B Dispenser(s)working: ❑Soap ❑Papertowel
C Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 1 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodborne]
PHFs are hot held at: OF. PHFs are cold held at: OF. /diseases
onditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork lated to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: illness policy that requires the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N e QFO? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N +Are leftovers saved? Y N 0 011s there a language barrier between inspector&QFO? Y N If yes indicate language spoken
List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions: Name(print):
Is cooling monitored for time&temp? Y N Is the monitoring of cooling re ed? Y N Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
•Obtain signature of the person who received the QFO responsibilities information at the time of the
Is there a produce washing policy? Y N *Describe what is wash and inspection:
where: NJ 1 Note: This report is a two page form gotal of 62 debitable items) Page 1 of 2
l� 6J
NAME OF ESTABLISHMENT DATE OF INSPECTION
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INITIAL
(INSPECTOR) ��, (PERSON
Page of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
kiez"-
INSPECTION FORM# REMARKS
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE) C 1�
Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager
Establishment: Date of Inspection. �'1
Address: Owner or Operator:
ADDITIONAL FOUR OINT ITEMS V
ak KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
-Unwrapped foods not re-served 4 31 Sewage disposal approved. 4
-Potentially hazardous foods not re-served -Operating as required
11 Toxic chemicals. No cross connections,back siphonage,backflow
-Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for:
-Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines
-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks
-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination rdesig
tfacilities. Adequate,convenient,accessible,
-Monitoring in compliance-Water quality in compliance ned,properly installed
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food:Original container,properly labeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present
4 Food worker:Clean outer clothes,effective hair restraints 43 Outeropenings protected againstentranceof insects/rodents
4 oors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed, 5 Floors graded,drained as required
located
6 Floor,walljuncturecovered
17 Nonfood-contact surfaces designed,constructed,maintained, 7 Mats removable,good repair,clean
installed,located
18 Single service articles,storage,dispensing
Exterior walking,driving surfaces,good repair,clean
19 No reuse of single service article 9 ails,ceilings attached,equipment properly constructed,good
20 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored
Equipment&Utensils; Cleanliness 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
23 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean
Nonfood-contact surfaces of utensils&equipment clean
55 Establishment and premises free of litter,no insect/rodent harborage,
8 Equipment/utensils,storage,handling no unnecessary articles
32 Proper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Propertoiletfixturesgrovided,good repair,clean entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof, lean ❑Routine Inspection bReinspection ❑ Preoperational Inspection
IN PE !!NMRGE- Other Inspection:
Demerit Score: •Include demerits from page 1
4 3 2 1 Total Rating
tur si ture
rin name pr t nameNAN
phone number title
DATE CORRECTIONS DUE:
Page 2 of 2 plus continuation pages Focused Inspection 1/2002
i
Establishment: Inspection Da#e: / Time: Roinsp Einsp
Address/City: Health Dept: /A.��S` Class: 1 2
Based on an inspection this day,the items marked C identify the violations in Operation or facilities which must be corrected by the date specified on page 2.
FACTOR ITEMS:Listing is not inclusive of all possible debitable items C N/O WA D KEY: C[complies] N/O[not observed] NIA[not applicable]
$ DNC[does not comply] 0[other] RTE[ready-to-eat]
2 — .
A Food workers have no4exposed infected lesions/burns
2 B Personnel with infection restricted
"MMMEW .. C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved
B Food cans in good condition(not dented,rusty,bloated,leaking) N A a ,°- � m 91 ._� t a `t���
A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) LOOO or
C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
0
E Handwashing at appropriate times ool
0
A Hot holding greater than or equal to 140 F. (whose beef�porkroasts 1300 F.) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 45oF. B Wounds covered adequately
C Proper cooling Wool C Proper sink used for handwashing
D Proper re-heating 0
E Proper internal cooking I consumer advisory posted
0 A Approved sanitizeravailable/adequate concentration of sanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp
B Proper food thermometer for product
L Proper sanitizin rocedure
C E Sanitizing between raw animal origin&ready-to-eat food
Thermometers appropriately placed in cooler units
0
A Cloths and/or sponges in good repair and clean
A Produce washed
B Wiping cloths kept in sanitizer between uses
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
F No pooling of eggs not cooked immediately Vol
Food containers stored off the floor
0
A No unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels/ drying device available
B Dispenser(s)working: ❑Soap ❑Paper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 *DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operates],DA[designated alternate],PHF[potentially hazardous food],FB[foodborne]
PHFs are hot held at: OF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N +To what temperature do you cook:
Poultry Ground Beef Pork What diseases related to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness pol es the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases to the N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N Is t anguage barrier between inspector&QFO? Y N tf des indicate language spoken
List products cooled: by CFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions: Name(print):
Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
Is cooling monitored for time&temp? Y N Is the ' nng of cooling recorded? Y N .Obtain signature of the person who received the QFO responsibilities information at the time of the
Is there a produce washing policy? Y ♦Describe what is washed and inspection:
where: Note: This report is a two page form(totes f 62 debitable items) Page 1 of 2
l �
Page_of_
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN ry r�,LS n j L, � DATE OF INSPECTION
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INITIAL(INSPECTOR) /V` INITIAL(PERSON IN CHARGE)
Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager
CC
c:kat�nsform2.crt 1 c!v V.,` .i4r ]; A,4t• 21,•C+ r N1 :3,`A,,
Establishment: << ti is Date of Inspection: z co 0
ddress: - ^cvv Owner or Operator: _ ��S�c ,cY A
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
-Unwrapped foods not re-served 4 31 Sewage disposal approved. 4
-Potentially hazardous foods not re-served
-Operating as required ;
11 Toxic chemicals. No cross connections,back siphonage,backflow
-Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for:
-Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines
-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks
-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 ourcesof food: Original container,properly labeled� 0 Garbage/rubbish storagearea/rooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 1 Garbage/rubbish disposed of in an approved manner,at approved frequency
Food dispensing utensils properly stored .(C J 2 Vermin Control: No insects/rodents present
pod worker:Clean outer clothes,effective hair restraints ji Outeropenings protected against entrance of insects/rodents
4 ors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed,
5 Floors graded,drained as required
located 6 Floor,wall juncture covered y "
17 onfood-contact surfaces designed,constructed,maintain c� 7 Mats removable,good repair,clean
installed,located `� S o�
8 Exterior walking,drlving surfaces,good repair,clean
18 Single service articles,storage,dispensing
19 No reuse of single service article 045 71all�s,ceilings attached,equipment properly constructed,good
0 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required
maintained installed located 50 Dustless cleaning methods used,cleaning equipment property stored
Equipment&Utensils• Cleanliness 51 Adequate lighting provided as required
1 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
23 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean
onfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodent harborage,
28 Equipment/utensils,storage,handling no unnecessary articles
32 Proper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
37 Proper toilet fixtures provided,good repair,clean
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection
Other Inspection:
ER N i CHARGE: Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
signature st ature
�J �N �'� ATTA
print name pri e
coy�( �- 2� � � x 2yg
;z Z�
phone number title DATE CORRECTIONS DUE: i 22
�- 9c ►,� Page 2 of 2 plus continuation pages Focused Inspection I/2002
Establishment: t,` Inspection Date: Z t c> Time: 5°4 REinsp
Address/City: C�ttstrt� Health Dept: `�4 lC Class: 1 2 3
Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C N/0 N/A IDNCl KEY: C[complies] NIO[not observed] NIA[not applicable]
3 Dill C[does not comply] 0[other] RTE[ready-to-eat]
;-
-Fe—IN. � 2 -C ;..fl NFA 4
2
of training program
A Food workers have no exposed infected lesions/burns
s ften r)ctcutnentattan
IT B Personnel with infection restricted
1 �PisaGed sourl wholesome,rtonadliter d C N/0 N/A a C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved 13 Handwashing facilir3es pr"OeidI nds hawnhed,cktan_ C N/0 NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature 0 D Personnel hands washed,clean/Proper handwash procedure .07E Handwashing at appropriate times �k
00
Mli
PIP
A Hot holding greater than or equal to 1400
F. (whole beef/pork roasts 130e F) A ❑ No eating ❑No smoking while working
B Cold holding less than or equal to 45oF. B Wounds covered adequately
C ropercooling C _,R49pl used for handwashing
D Proper re-heating 0-1 ol
E Proper internal cooking/consumer advisory posted 0-1
0 Approved sanitizeravailable/adequate concentration of sanitize
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate ti'v n W�7 C Adequate ❑dishwashersanitizer V al rinse temp
D Proper sanitizin rocedure
B Proper food thermometer for product LP.
E Sanitizing between raw animal origin&ready to�at food
C Thermometers appropriately placed in cooler units
0 �
..t.
A Cloths and/or sponges in good repair and clean
B Wiping cloths kept in sanitizer between uses
A Produce washed
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food—contact surfaces clean
F No pooling of eggs not cooked immediately 0
8 Food containers stored off the floor
0o
A No unnecessary handling RTE and/or cooked foods with bare hands A Soap I paper towels/drying device available
B Dispenser(s)working: ❑Soap ❑Paper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean I waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
O •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodbome]
PHFs are hot held at: OF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork What diseases related to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness policy that requires the food worker to report specific illness conditions
Are temperatures recorded/logged for cold holding foods/equipment? Y N and diseases to the QFO? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N If yes indicate language spoken
List products cooled: by QFO/DA: *Can the CFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions:Name(print):
Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
Is cooling monitored for time&temp? Y N Is the monitoring of cooling recorded? Y N .Obtain signature of the person who received the QFO responsibilities information at the time of the
Is there a produce washing policy? Y N *Describe what is washed and inspection:
where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
-po N S.
7c�� O-P S19U44
1540 SULLIVAN AVENUE• SOUTH WINDSOR, CT 06074
l�OSOR•CO TELEPHONE(860) 644-2511
December 11, 2008
Jessica Burney
Bellini's
538 Evergreen Way
South Windsor, CT 06074
Re: Food Service Establishment Inspection of Bellini's located at 538 Evergreen Way in
South Windsor, Connecticut
Dear Ms. Bumey:
On December 10, 2008, a food service inspection was conducted at Bellini's located at 538
Evergreen Way in South Windsor, Connecticut.
At the time of the inspection, the rating score was 78 with one 4-demerit point item in violation.
According to the Connecticut Public Health Code, a food service establishment must maintain a
rating score of 80 or higher with NO 4-demerit point items in violation.
Corrections of the violations noted must be made by December 30, 2008.
If you have any questions I can be reached at(860) 644-2511, extension 248.
Sincerely,
Robert De Vito, R.S.
Environmental Health Officer
iL
t.� n Page of
„�.
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOOWN 50k ��2�rr�t,� i,� DATE OF JINSPECITION
INSPECTION FORM# REMARKS
r22 de � ,L3rZ. LA
12
3.A-^E`2_ Pv� L%,,,f q7 F
Z. c-.�z 4
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: 1 st-White-Health Department 2nd-Yellow- Owner/Manager
I
Establishment. I_L i Date of Inspection: `3 ^
ddress: 5��X Owner or Operator:
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 1 Foods not re-served.
-Unwrapped foods not re-served 4�, 31 Sewage disposal approved.
-Potentially hazardous foods not re-served 74
-Operating as required
11 Toxic chemicals. No cross connections,back siphonage,backflow
-Stored properly,labeled properly,used properly Proper type/installation/backflow prevention device/air gap for:
-Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines
-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks
-Pesticides/rodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance designed,properly installed
®Rc—od
onitoring in
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
cesof food:Original container,properylabeled 0 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
entially hazardous food properly thawed 1 Garbage/rubbish disposed of in an approved manner,at approved frequency
od dispensing utensils properly stored 2 rmin Control:No insects/rodents present
worker:Clean outer clothes,effective hair restraints Outeropenings protected against entrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean
6 Aod-contact surfaces designed,constructed,maintained,installed, 45 Floors graded,drained as required
located
6 Floor,wall juncture covered
17 Nonfood-contactsurfacesdesigned,constructed,maintained, 7 Mats removable,good repair,clean
installed,located
8 Exterior walking,driving surfaces,good repair,clean
18 Single service articles,storage,dispensing
19 No reuse of single service article 9 Walls,ceilings attached,equipment properly constructed,good
0 Dishwashing facilities approved design,adequately constructed, repair,clean.Wall&ceiling surfaces as required
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored
Equipment&Utensils: CI anlin 51 Adequate lighting provided as required
1 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
2 ccurate thermometers provided,dish basket,if used 44' ooms adequate,clean,adequate lockers provided,facilities clean
27 nfood-contact surfaces of utensils&equipment clean
5 Establishment and premises free of litter,noinsect/rodentharborage,
8 Equipment/utensils,storage,handling no unnecessary articles
32 Proper disposal of wastewater 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Propertoiletfixturesprovlded,good repair,clean entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean outine Inspection ❑Reinspection ❑ Preoperational Inspection
Other Inspection:
INSPECTOR. PER E Demerit Score: *Include demerits from page 1
�-- f 4 3 2 1 Total Rating
signature signature
print name _ print name I
�LtL ZS t i � UUU
phone numb r title DATE CORRECTIONS DUE: (Z ►+
Page 2 of 2 plus�_continuation pages Focused inspection 1n002
Establishment: Inspection Date: 9 t t Time: I: i ,.vim a2in k REinsp
Address/City: 95bk Health Dept: W, VA-a Glass: 1 2 s 4
Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS:Listing is not inclusive of all possible debitable items C NI WA JDNC I KEY: C[complies] N/O[not observed] N/A[not applicable]
$ DNC[does not comply] 0[other] RTE[ready-to-eat]
r
-� A Food workers have no exposed infected lesions/burns
2 B Personnel with infection restricted
APP* ICQ( 06M8'�1plt8d �ertet! �` •N/A ° C Communicable disease of worker reported to local health director lo
A Approved shellfish,finflsh,meat& ppoultry USDA approved
iz
h� `>Tfq `', ,clenl r r G N/O' NlA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
of
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
0
E Handwashing at appropriate times
A Hot holding greater than or equal to 140 F. (Whole beef/pork roasts 1300 F.I A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 45o F. B Wounds covered adequately
C Proper cooling 77 Proper sink used for handwashing
D Proper re-heating 0
E Proper internal cooking/consumer advisory posted
Approved sanitizer available/adequate concentration of sanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate 11 C Adequate' dishwashersanitizer NLi al rinse temp
B Proper food thermometer for product
D Proper sanitizin rocedure
C Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
0
0
- :=.— I=�)
-Cloths and/or sponges in good repair and clean Rom.
I ol
A Produce washed
B Wiping cloths kept in sanitizer between uses
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards 1 sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food—contact surfaces clean
F I No pooling of eggs not cooked immediately 0
8 Food containers stored off the floor
m raartowels/ evice availableNo unnecessary handling RTE and/or cooked foods with bare hands Soap ❑Paper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodbome]
PHFs are hot held at: OF. PHFs are cold held at: OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken? Y N *To what temperature do you cook:
Poultry Ground Beef Pork What diseases related to FB illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness policy that requires the food worker to report specific illness conditions
Are temperatures recordedllogged for cold holding foods/equipment? Y N and diseases to the QFO? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N If yes indicate language spoken
List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N
Describe cooling methods: Indicate who answered the above questions:Name(print):
Is cooling monitored for time&temp? Y N Is the monitoring of cooling recorded? Y N Indicate the title of above person(circle all that apply):CFO DA Mgr Cook Owner FW
•Obtain signature of the person who received the CFO responsibilities information at the time of the
=where:
washing policy? Y N *Describe what is washed and inspection:
Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
Page_of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
.CONTMUATION SHEET
NAME OF ESTABLISHMENT TOWN Sal w DATE OF INSPECTION
s(. lrvl ,S SOvi�1 l.J��SeQ� 1 IS O�
Impaction Form M Remarks:
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: st-White-Health Department 2nd-Yellow-Owner/Manager
c:ken\imform2.cn
Establishment: t-4-I `S Date of Inspection v
Address: IS b 4 E wlle_G._� Owner or Operator: �'l t ` S /
ADDITIONAL FOUR POINT ITEMS
KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
-Unwrapped foods not re-served 4 31 Sewage disposal approved.
-Potentially hazardous foods not re-served erating as required
11 Toxic chemicals. 4.l cross connections,back siphonage,backflow
aap
-Stored properly,labeled properly,used properly Proper t 'nstallati reven I-Food equipment -Dish machines n air for:
-Sanitizes concentration not to exceed maximum permitted-No unnecessary toxics on the premises -Soda system carbonator -Beverage dispensers -Toilet tanks-Pesticides/rodenticides properly dispensed -Chemical dispensers Ice machinesProper drain for: 'CAS 'L(
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food: Original container,properly labeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,dean
5 Potentially hazardous food properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
0Fz6d dispensing utensils properly stored 42 Vermin Control: No insects/rodents present
4 Food worker:Clean outer clothes,effective hair restra 43 Outeropenings protected against entrance of insects/rodents
4 loors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed, 5 Floors graded,drained as required
located
6 Floor,wall juncture covered
17 Nonfood-contact surfaces designed,constructed,maintained, 7 Mats removable,good repair,clean
stalled,located
8 le service articles,storage,dispensing
8 Exterior walking,driving surfaces,good repair,clean
9 No reuse of single service article 9 alls,ceilings attached,equipment properly constructed,good
epair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed,
maintained installed located 50 stless cleaning methods used,cleaning equipment properly stored
EEquipment&Utensils: Cleanliness 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature 53 Rooms&equipment hoods,ducts,vented as required
23 Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean
27 nfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodent harborage,
28 EquipmenUutensils,storage,handling no unnecessary articles
32 Proper disposal of wastewater 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
36 Toilet rooms enclosed with self-closing door 58 No live birds,turtles,or other animals(except guide dogs)
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered, 1.
rodent proof,clean kgRoutine Inspection ❑Reinspection ❑ Preoperational Inspection
0 Inspection:
INSPECTOR.! ;1rX1
4
Demerit Score: *Include demerits from page 1
3 2 1 Total Rating
signa ure si nature
ZJ�t1V rf J�`TT7 �1.o�.s, re-
YILI (":5)3 �P l r
print name on name D (l , l0 �1
�y L{- 25 t ( " o-. 5 t. DATE CORRECTIONS DUE: )))
phone num er title
aria %e v'_-0 Page 2 of 2 plus-_-t continuation pages Focused Inspection l/2002
(M V2)
s �
Establishment: r3��1. 1 are aa'S Inspection Date: ,it - 1 oV Time:12-,O() nsp REins
Address/City: jS-'C>( L-v%gj-C,,t,_x t,3 u-j Health Dept: S-x..1T%t Vi i = a s: z 3 4
Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C W N/A IDNC I KEY: C[complies] N/O[not observed] N/A[not applicable]
3 DNC[does not comply] 0[other] RTE[ready-to-eat]
y
A Food workers have no exposed infected lesions/burns
01
�nf B Personnel with infection restricted
p ► i ''x r a �i s � _ ' , _ A 4.
w C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved
B Food cans in good condition(not dented,rusty,bloated,leaking) A = *Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature 70 D Personnel hands washed,clean I Proper handwash procedure
0 E Handwashing at appropriate times Vol
0
r���, r -��
A Hot holding greater than or equal to 140 F. (Whole beef/pork roasts 1300 F.) loo, A ElNo eating ❑ No smoking while working
B Cold holding less than or equal to 45°F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing
7 Proper re-heating 0 lA-0-N4> <a,t&A4L o
E Proper internal cooking/consumer advisory posted 11
0 A Approved sanitizeravailable/adequate concentration of sanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food sanitized at least every 4 hours WOO
01
A Food thermometer available and accurate C Adequate ❑dishwashersanitizer 0 final rinse temp
D Proper sanitizin
B Proper food thermometer for product
procedure
C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food
0
0
000lA Cloths and/or sponges in good repair and clean
A Produce washed
B Wiping cloths kept in sanitizer between uses
O
11*110
B Raw meats not stored/prepared near ready-to-eat foods
C Food covered properly ZE:
A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard B Single use gloves changed when soiled
E No unauthorized personnel C Food--contact surfaces clean
F No pooling of eggs not cooked immediately 0
ood containers stored off the floor
100
ON
Soap/paper towels/ drying device available
A No unnecessary handling RTE and/or cooked foods with bare hands B
Dispenser(s)working: ap Cigaper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean I waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice 0
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. KEY: QFO[qualified food operator],DA[designated aftemate],PHF[potentially hazardous food],FB[foodbome]
PHFs are hot held at: OF. PHFs are cold held at: — LA I OF. Describe illness conditions when you would exclude a food worker from working:
Are internal cooking temperatures taken?®N ♦To what temperature do you cook: %CT%C. I CAD-j .k,%f%e wvcx�IV&p Vb M-^Nl�
Poultry Ground Beef ( "b 1 A%t•/ Pork t to 9 What diseases related to FB illness are you required to repo�.to the local health department?
Roasts A Other 2p QJC vI . S A�on+.�u� T�� t
Describe re-heating procedures: Z&v*wA'M t J J l IZV Is there a written illness p that requires the food worker to report specific ill conditions
Are temperatures recorded/logged for cold holding foods/equipmen. YD and diseases to the QF *Do you have a paid sick leave policy N
Are foods cooked in advance and cooledC Y N Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y es indicate language s )ken
List products cooled: ALft—gmo1 Caxac-sec S.0")K .�<a�� by QFO/DA: *Can the QFO/DA read the inspection report N
S
Describe cooling methods: t wAw,A 'Ib w+4L1L %rJ Indicate who answered the above questions: Name(print): t�JV t
Is cooling monitored for time&temp? N Is the monitoring of cooling recorded? Y Indicate the title of above person(circle all that apply.QF DA Mgr o Owner W
Obtain signatu a of he person w e he QFO ibilitie the of the
Is there a ro uce washin inspection:
p Sg po� Y N ♦Describe what is washed and
where: Z ' / L�T1�tC.�r 1�S[tL.nJ Note: This report ij a two page form(total of 62 debits items) Page 1 of 2