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Home My WebLink AboutFood Service Establishment Inspection 50 (6) Establishment: Inspection Date: Time: ' Oin REinsp ddress/City: l Health Dept: Class: 1&3 4 Based on an inspection this day,the Xitems marke ident[fy 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 N/O N/A DNC ]-may KEY: C[complies] N/O[not observed] N/A[not applicable] 3 DNC[does not comply] 0[other] RTE[ready-to-eat] 61 001#1iati 1lite�nate r 2 r Acted C At/Q NIA 41 O Written documentation of training program A Food workers have no exposed infected lesions/burns 1 Approved source,wholesome,nonaduiterated C Nf0 f+ilA 4 B Personnel with infection restricted A Approved shellfish,finfish,meat& oultry USDA annmved C Communicable disease of worker reported to local health director B Food cans in good condition(not dented,rusty,bloated,leaking) 13 Handwastung Wiittes provided,hands washed,clean C N/0 NIA 4 C Wholesome/nonadulterated foods/safe A Handwash facilities in all food prep/dispensing&warewash areas D Commercial products(no home grown/Canned food) B Handwash facilities in or immediately adjacent to toilet rooms E Potentially hazardous foods received at proper temperature C Handwash facilities accessible/convenient to use 0 D Personnel hands washed,clean/Proper handwash procedure 3 Paetdtat itazartrrs iaod, ets ►pert r " rF E Handwashing at appropriate times daei»g sorage,pr off,seavase aad�pQtra 0 - - 1$ csoifhyni practicds C PUO' WA Z A Hot holding greater than or equal to 1400F. (Whole beef/pork roasts 130o 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 0 E Proper internal cooking/consumer advisory posted Z. A Approvedsanitizeravailable/adequate concentration ofsanit[zer Adegttte# crtitreso frrarrf# ttn protect Food-contact surfaces and utensils rrtotnet�ils faros aci=` used for potentially tmperaWrether n 3 B 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 Proper sanitizin rocedure C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food 0 0 f"titd'prta# afie `citst+otatg ; aratft, .x a A - itirt °et' fh;'a, - C'NIO NIA 1 display,service 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 A Food equipment clean,utensils clean,equipment interiors clean D Adequate splash guards/sneeze guard E No unauthorized personnel B Single use gloves changed when soiled F No pooling of eggs not cooked immediately Food--contact surfaces clean 8 Food containers stored off the floor 0 9 Haodlittg crf food'rrtiniilired' t 0 NIA 1 -�.- ., fMinimize unnecessary handling RTE and/or cooked foods with bare hands A Soap/paper towels/ drying device available food handling,other than ready-to-eat,with bare hands B Dispenser(s)working: ❑Soap El Paper towel C Handwash sink(s)clean/waste receptacle at handwash sink equate utensil(s)for dispensing food/ice •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: IF. PHFs are cold held at: IF. 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 Il-ygs 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 Establishment: Date of Inspection: 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. -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 preventiondevice/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-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 storagearea/rooms,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 t, 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, 5 Floors graded,drained as required Gated 6 Floor,wall juncture covered 17 nfood-contact surfaces designed,constructed, maintained, installed,located 7 Mats removable,good repair,clean 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 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 541 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/rodent harborage, 28 Equipment/utensils,stprage,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 _11 ❑Routine Inspection ❑Reinspection ❑ Preoperational Inspection INSPECTOR: MIRR Other Inspection: Demerit Score: •Include demerits from page 1 4 sigure 3 2 1 Total Rating ` Xt printname print name �1 '�% R� �� DATE CORRECTIONS DUE: phon number title 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 TO DATE OF INSP_CT ON INSPECTION FORM# REMARKS or 01-4 Zx A ( (0►'1 a � �1 ��—�iirf 7 s INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE) is ibution: lst-White-Health Department 2nd-Yellow-Owner/Manager