HomeMy WebLinkAboutFood Service Establishment Inspection 17 (18) i
Establishment: ,t, " Inspection Date: Time ° REinsp
Address/City: I Health Dept: y ti
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 debatable items C IV INIA DNCI KEY: C[complies] N/O[not observed] NIA[not applicable]
66 troot( p rotor t g DNC[does not comply] 0[other] RTE[ready-to-eat]
61 Designated Alternate 2 12 ei+$i6ti off with infection res cted C 0 4
62 Written documentation of training program A Food workers have no exposed infected lesions/burns
2 B Personnel with infection restricted
1 Approved source,wholesome,nonadtriterated C No N/A 4 C Communicable disease of worker reported to local health director
B o roved shellfish,condition
meat&poultry USDA approved 13 Handwashing facilities provided,'hands washed,clean C ( q 4
B Food cans in good condition(not dented,rusty,bloated,leaking)
A Handwash facilities in all food prep/dispensing&warejareams
C Wholesome/nonadulterated foods/safe
B Handwash facilities in or immediately adjacent to D Commercial products(no home grown/canned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash
0
E Handwashing at appropriate times
Poterltiaity hazardottafoodmeetsternpdrature.req meets C,fist
duriog sforage,piepatatign,dieplay,senrla$end traasaor#atlon �
'Good hygle''h1c practices C WO WA
A Hot holding greater than or equal to 1400F. (Whole beef/pork roasts 1300 F.) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 450F. B Wounds covered adequately 6010
C Proper cooling C Proper sink used for handwashing
D Proper re-heating 0
roper internal cooking/consumer advisory posted 24 o Sat2tior#rriSe �r ce€ tl) C 'N/(i" 2
�., 3
0 a q u A Approvedsanit[zeravailable/adequateconcentrationofsanitizer
4 Adequate fac�tles to matnta#n prod' t t I'Wo N/A- 2' B Food contact surfaces and utensils used for potentially00,
�nlperature,tltermarraeters provided hazardous food sanitized at least every 4 hours
A Food thermometer available and accurate C Adequate dishwas ersam i ❑final rinse temp
B Properfood 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 Q
t`a.Q r�wtpi �c#oths` C Ni0 NlA 1
i=aid prcata,6 if r"i �s rage,prepafa
display,servtce and transportation 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 0
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 t
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
, 1 ,� rer pr tied es '2
isort paidZjl , ..+
Handling of food n'tirrimlzed C NO
A No unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels/ drying device available '
B 5spenser(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
OF
0 •DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS
The following information is not debitable and does not affect your score. Y. QFO[qualified food operator],DA[designated alternate],PHF[potentially hazardous food],FB[foodborne]
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 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 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):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 washed and inspection:
where:
Note: This report is a two page form(total of 62 debitable items) Page 1 of 2
t
Establishmeh : ` Date of Inspection:
[Address: 1 z�ltvtd} Owner or Operator:
ADDITIONAL FOUR POINT ITEMS tj KEY: DNC [DOES NOT COMPLY] �..
6 Foods not re-served.
4 osal approved.disp
-Unwrapped foods not re-served 31 Sewage4
-Potentially hazardous foods not re-served -Operating as requiredii
No cross connections,back siphonage,backflow
11 Toxic chemicals. 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 -Soda system carbonator -Beverage dispensers -Toilet tanks
-No unnecessary toxics on the premises -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 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
5 Potentially hazardous food properly thawed 41 Garbage/rubbish 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
14 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
17 Nonfood-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 Ils,ceilings attached,equipment properly constructed,good
repair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed,
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
fWash 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
onfood contact surfaces of utensils&equipment clean 55 Establishment and premises free of litter,no insect/rodentharborage,
quipmentlutensils,storage,handling no unnecessary articles
232Proper 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 581 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:
INSPECTOR: N IN A Demerit Score: *Include demerits from page 1
1 4 3 2 1 Total Rating
i nature Vignatu—PUr
int name
p print name �
TESL °M tNGr DATE CORRECTIONS DUE:
phone number title
fir� � d t rJ�meµ- Page 2 of 2 plus continuation pages Focused Inspection 1/2002
. Page of�
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
INSPECTION FORM# REMARKS
vU f
-P t
� d � icep - 1
t In
X�
l �
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: 1st-White-Health Department 2nd-Yellow-Owner anag
Page of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF SPECTION
SPEC ON REMARKS
FORM#
f tC-
w— CIA,
2T 4n C.') C�= M::91.w
1-9
, .
W LI
--�/1 e2
1 ,LOf r
L s
cam-
s
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE
Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager