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Home My WebLink AboutFood Service Establishment Inspection 97 (3) Establishment: Inspection Date: Time: _&D Rt)ins REinsp ddress/City: Health Dept: 1�.g 1/ Clasc!)2 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 N/0 I N/A DNC (6pierd of �a a R� 3 DNC[does not comply] 0[other] RTE[ready-to-eat] 42 6f$oiiria7*Ittr`ii tidn restricted 61 Designated Alternate2 C Nft3 WA 4 62 Written documentation of training program 2 A Food workers have no exposed infected lesions/burns B Personnel with infection restricted 1 Approved source,wholesome,nonadulterated C N10 111A 4C Communicable disease of worker reported to local health director A 1 Approved shellfish,finfish,meat&poultry USDA approved 13 Handmishing facilities provided,hands washed,clean C NO NfA 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 V I I D Personnel hands washed,clean/Proper handwash procedure 0 VIt E Handwashing at appropriate times 3 potentially hazardaus`.feod tirretif t i t 0 dtidsg stags,praparotionr tiispiit 4610010 na (tert6 ; 1 S °mod h sc�i wc'practices C N/0 N/A 2 A Hot holding greater than or equal to 1400F. (Vmoie beef/pork roasts 130e F.) A ❑ 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 D Proper re-heating V.Z0 E Proper internal cooking I consumer advisory postedw � >( water t: tntCt C .fit} 2 0 A Approvedsanitizeravailable/adequate concentration ofsanitizer 4 Affequate'f coif ,t4(nigirktalt pf6cl t '> B food-contact surfaces and utensils used for potentially to MY ,t�trrtrt�onrtetei3 plo id "_ r R hazardous food sanitized at least every 4 hours A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp Proper B Properfood thermometer for product D rocedure C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food 0 0 7 Food prtrteeted cltrting" 'f age;prepat d } .7. ,. s 2 ; display,service and trartstsportation A Cloths and/or sponges in good repair and clean A Produce washed B Wiping cloths kept in sanitizer between uses 0 B Raw meats not stored/prepared near ready-to-eat foods C Food covered properly le I MEW IN in Ell oe A 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 floorE 9 Handling of food tnlnirriizecl +± sfa!lo$.pr dael} £ C t?'' , 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. M: QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food], FB[foodbornej 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 tempera ook: Poultry Ground Beef ork What diseases related to FB illness are you required to re e e ment? Roasts Other Describe re-heating procedures: Is there a written illness policy t ires the food worker to report specific illness conditions Are temperatures recorded/logged for col ing foods/equipment? Y N and dise2ses to the N *Do you have a paid sick leave policy? Y N Are foods cooked in advance cooled? Y N *Are leftovers saved? Y N Is there a language barrier between inspector&QFO? Y N If ves indicate language spoken List products cooled: by QFO/DA: *Can the QFO/DA read the inspection report? Y N Describe cooking methods: Indicate who answered the above questions: Name(print): rl shr 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):QFO DA Mgr Cook Owner FW *Obtain signature of the p�,sgh w received t e s nsibilities information at the time of the Is there a produce washing policy? Y N *Describe what is washed and inspection:P where: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2 Establishment: Date of Inspection: 'L )3 Address: 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. 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 -Chemical dispensers -Ice machines -Pesticides/rodenticides properly dispensed Proper drain for: 29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines -Well/well head protected from contamination-Water quality in compliance 35 Toilet facilities. Adequate,convenient,accessible, -Monitoring in compliance designed,properly installed OTHER ITEMS KEY: DNC [DOES NOT COMPLY] 2 Sources of food: Original container,properly labeled 40 Garbage/rubbish storagearealrooms,enclosures-properly constructed,clean 5 Potentially hazardous food properly thawed 41 Garbagelrubbish disposed of in an approved manner,at approved frequency 10 Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present 14 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, 45 Floors graded,drained as required located 6 Floor,wall juncture covered 17 Nonfood-contact surfaces designed,constructed,maintained, 7 Mats removable,good repair,clean installed,located 18 Single service articles,storage,dispensing 481 Exterior walking,driving surfaces,good repair,clean 19 No reuse of single service article 9 Walls,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 properlystored 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 27 Nonfood-contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodentharborage, 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 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) 37 Proper toilet fixtures provided,good repair,clean 59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at entran (s),smoking area indicated by sign(s) 39 Approved garbage/rubbish containers,adequate number,covered, rodent proof,clean Woutine Inspection ❑Reinspection ❑ Preoperational Inspection Other Inspection: INSPECTOR: PERSON IN HARE / Demerit Score: *Include demerits from page 1 4 3 2 1 Total Rating signature s' nat ref fo YO Zo S 0^ e JCD print name mt name (� ("LAy_a' DATE CORRECTIONS DUE: phone number title Page 2 of 2 plus��continuation pages Focused Inspection 1/2002 r Paged of �I�SPLCrION REPORT FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION INSPECTION REMARKS FORM# LID, Uvv1 V�'1 &L� , s6� ° eVt � tea ' INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE) CV V Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager