HomeMy WebLinkAboutFood Service Establishment Inspection 85 (17) Establishment: Inspection Date: Time: (`Z�� "inspTREnspddress/City: 9S S S6�itJah, �2 Health Dept: S - "NA ��✓� Class: 1 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/O N/A DNC KY: C[complies] N/O[not observed] N/A[not applicable]
3 DNC[does not comply] 0[other] RTE[ready-to-eat]
_
2 A Food workers have no exposed infected lesions/burns
B Personnel with infection restricted
N/0[NIA' 4,
C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved IS,
B Food cans in good condition(not dented,rusty,bloated,leaking) It hi00 of prov*d,,han wa d, ,,WA 4'
A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulterated foods/safe
D Commercial products(no home grown/canned food) B Handwash facilities in or immediately adjacent to toilet rooms
C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean/Proper handwash procedure
0
E Handwashing at appropriate times
0
0' NfA,
A Hot holding greater than or equal to 1400F. (Whole beef/pork roasts 130e F) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 450 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 ofsanitizer
B Food-contact surfaces and utensils used for potentially
hazardous food s itized at least every 4 hours
A Foodthermometer available and accurate C Adequate ishwashersanitizer ❑final rinse temp
B Properfoodthermometerforproduct D Proper sa itizin procedure
C Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
0 O
gn
s A A <Cloths and/or sponges in good repair and clean
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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 60o
A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards/sneeze guard 11 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 floor
0
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A S
A No unnecessary handling RTE and/or cooked foods with bare hands oap I paper towels/ drying device availableJ B
B Dispenser(s)working: ❑Soap ❑Paper towel
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 akemate],PHF[potentially hazardous food],FB Ifoodborne]
PHFs are hot held at: OF. PHFs are cold held at: F. 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 Roasts Other What diseases related to FB illness are you required to report to the local health department?
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 U-M 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
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Establishment: Date of Inspection:
ddress: S4 Owner or Operator: Uh
ADDITIONAL FOUR POINT ITEMS cz
KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served.
-Unwrapped foods not re-served 41 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 prevention device/air gapfol:
-Sanitizer concentration notto 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 35 Toilet facilities. Adequate,convenient,accessible,
-Water quality in compliance
-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,dean
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 Outeropenings 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
located
6 Floor,wall juncture covered
17 N nfood-contact surfaces designed,constructed, maintained, 7 Mats removable,good repair,clean
installed,located
18 Single service articles,storage,dispensing
8 Exterior walking,driving surfaces,good repair,clean
19 No reuse of single service article 49 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
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/rodent harborage,
-0 Equipment/utensils,storage,handling no unnecessary articles
2 oper disposal of waste water 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
58 No live birds,turtles,or other animals(except guide dogs)
36 Toilet rooms enclosed with self-closing door
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean
entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean outine Inspection ❑Reinspection 0 Preoperational Inspection
Other Inspection:
INSPECTOR: PSON INCAR GE: Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
si ture signature
s te e, a�my_� 2 c
print name print name 2
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phone number title DATE CORRECTIO S DUE:
Page 2 of 2 plus kcontinuation pages Focused Inspection EU
Page3 of 3
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN ( -IJ YA a w 4 J DATE OF INSPECTION
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INSPECTI
FORM oN REMARKS
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: 1 st-White-Health Department 2nd-Yellow-Owner/Manager