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Establishment: nspection Date: Time: _00iii RE[nsp
Address/City: 2.4 Health Dept: class: 1 z C4
Based on an Inspection this day,theorems marked DNC identify t1fi 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 WO WA DNC KEY: C[complies] N/O[not observed] N/A[not applicable]
3 DNC[does not comply] 0[other] RTE_[ready-to-eat]
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rten� � �@ cif trallni} A Food workers have no exposed infected lesions/burns
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B Personnel with infection restricted
! ApR[c ed SOUTH uYffo es e�.nonaddtte ated C N/0N/A 4 ommunicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved 43 444indmilithing facliftilles Provided,hands washed,clean C 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/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 D Personnel hands washed,clean/Proper handwash procedure
E Handwashing at appropriate times
A Hot holding greater than or equal toM140oF. (Whole beef/porkroasts 1300 el A ❑ No eating ❑ No smoking while working
Cold holding less than or equal to 450 F. B Wounds covered adequately
C Proper cooling Proper sink used for handwashing
D Proper re-heating
tFood
roper internal cooking/consumer advisory posted Approved sanitizer available/adequate concentration of sanitizerFood-contact surfaces and utensils used for potentiahazardous food sanitized at least every 4 hours
thermometer available and accurateAdequate ❑dishwashersanitizer ❑final rinse temp
roperfood thermometer for product
D Pro er sanitizing procedure
Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
Cloths and/or sponges In good repair and clean
7BRaw
uce washeding cloths kept in sanitizer between uses
eats not stored/prepared near ready-to-eat foods
Food covered properly A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard Vg Single use gloves changed when soiled
No unauthorized personnel Food contact surfaces clean
01 No pooling of eggs not cooked immediately 0
8 ood containers stored off the floor
No unnecessary handling RTE and/or cooked foods with bare hands Soap/paper towels/ drying device available
B Dispenser(s)working: OSoap aper towtel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clean/waste receptacle af handwash sink
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. JSE—Y: QFO[qualified food operator],DA[designated altemate],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 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&CFO? Y N 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 FIN
•Obtain signature of the person who received the QFO responsibilities information at the time of the
TIs there a produce washing policy? Y N *Describe what is washed and inspection:
here: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
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