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Home My WebLink AboutFood Service Establishment Inspection 70 (2) i Establishment: S.4 Inspection Date: Ti me:k> oins RE[nsp ddress/City: va Health Dept: Class: 1 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 I NIO I N/A JDNC I KEY: C[complies] N/O[not observed] NIA[not applicable] 3 1 DNC[does not comply] 0[other] RTE[ready-to-eat] 2 ` ,. A Food workers have no exposed infected lesions I burns B Personnel with infection restricted Y" $' NIA ' 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/nonadulteratedfoodslsafe 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 oeE Handwashing at appropriate times 0 1 � � cauAs A Hot holding greater than orequal to 140oF. (whole beef/pork roasts fsooF.) 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 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 1 Adequate ❑dishwashersanitizer ❑final rinse temp L Proper sanitizin procedure B Proper food thermometer for product E Sanitizing between raw animal origin&ready-to-eat food C Thermometers appropriately placed in cooler units 0 0 A Cloths and/or sponges in good repair and clean I MY 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 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 Food containers stored off the floor 0 A No unnecessary handling RTE and/or cooked foods with bare hands 111!7 / drying device available '17g: ❑Soap ❑Paper towel B Minimize food handling,other than ready-to-eat,with bare hands ean I waste receptacle at handwash sink C Adequate utensil(s)for dispensing food/ice O I •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: 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 QFOIDA: *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 cooling recorded? Y N .Obtain signature of the person who received the QFO responsibilities information at the time of the rwhere: e a produce 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 Establishment: 2_1 Date of Inspection: f // 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. 4' -Potentially hazardous foods not re served 37 -Operating as required 11 Toxic chemicals. No cross connections,back siphonage,backflow re -Stored properly,labeled properly,used properly Proper backflow oventiondevice/air gap for: -Sanitizer concentration not to exceed maximum permitted -Food equipment -Hose connections -Dish machines -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 In rdTeosi etacilities. Adequate,convenient,accessible, -Monitoring in compliance-Water quality incompliance gned,properly installed OTHER ITEMS KEY: DNC [DOES NOT COMPLY] 2 Sources of food: Original container,properly labeled 40 Garbage/rubbish storage area/moms,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 4 loors: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 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 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,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) 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 jXProutine Inspection OReinspection E Preoperational Inspection Other Inspection: INSPECTOR: PERSON IN CHARGE: Demerit Score: *Include demerits from page 1 "Q's� 4 3 2 1 Total Rating rg ure J j sig ature A l 4,k,41 V t "" p X; :K. rint name print name 333 yO r9?Y_�1( - r-Rr� L �-5 EE E: phone number title DATE CORRECTIONS DU k Page 2 of 2 plus continuation pages Focused Inspection ll2 1 Pag 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 CZ �� " Loch, o OS-7- -- 4.1ad, 6W C� rac �— v� cC)LI, kc-.� C14 r r , Lug INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE) Distribution: 1 st-White-Health Department 2nd-Yellow-Owner/Manager