HomeMy WebLinkAboutFood Service Establishment Inspection 17 (8) Establishment: �� Inspection Date: Time: M12
Address/City: ECfi Health Dept: S (IJll i,J 1� C1/Based on an inspection this day,the items marked DNC identify the violations in operation or facilities which must be corrected by the date specifi
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C /0 1 NIA DNC I KEY: C[complies] N/0[not observed] N/A[not applicable]
60 Qualified Food Operator 3 DNC[does not comply] 0[other] RTE[ready-to-eat]
k-1061 Designated Alternate 2
12 Persoianel with infection restricted C O NIA 4
62 Written documentation of training program 2 A Food workers have no exposed infected lesions/burns
B Personnel with infection restrictedLo
1 Approved source,wholesome,nonadulterated NIA 4 C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved 13 Handwashing facilities provided,handswashed,clean C NO NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadu Iterated foods/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 D Personnel hands washed,clean/Proper handwash procedure
0
E Handwashing at appropriate times
3 Potentially hazardous food meets temperature requirements C WO INA 4 0
during storage,preparation,display,service and transportation
15 Good hygienic practices UO WA 2
A Hot holding greater than or equal to 1400F. (whole beef/pork roasts 1300 e) 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 24 -Sanitization rinse(hot water chemical) NI0 NIA 2;'
0 A Approved sanitizeravailable/adequate concentration ofsanitizer
4 Adequate facilities to maintain product C p NIA 2 B Food-contact surfaces and utensils used for potentially
temperature,thermometers provided hazardous foods nitized at least every 4 hours
A Food thermometer available and accurate C Adequate f . ishwashersanitizer ❑final rinse temp
B Proper food thermometer for product
D Proper sanitizin procedure
C Thermometers appropriately placed in cooler units
E Sanitizing between raw animal origin&ready-to-eat food
0 0
Food protected during storage,preparation, C WO N! 25 Clean wiping cloths C O NIA 1
2
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 26 Food-contact surfaces clean C pl N/A 2
C Food covered properly 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 O
8 Food containers stored off the floor 30 Hot and cold water under pressure,provided as required' NI0 NIA 2
0 38 Handwashing accessories provided cy,00 NIA 1
9 Handling of food minimized L1 WO WA 1 2
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 1 •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: 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 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):
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 CFO 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
Establrahrrt� t r Date of Inspection; ills
dress: Owner or Operator: c n
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
37 No cross connections,back siphonage,backflow 11 Toxic chemicals. 4 Proper type/installation/backflow prevention device/air gap 4
-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. 4 -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination 35 Toilet facilities. Adequate,convenient,accessible, 4
-Water quality in compliance designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY] f_
2 Sources of food: Original container,properly labeled 1 0 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean li
5 Potentially hazardous food properly thawed 2 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
0 Tod dispensing utensils properly stored 1 42 Vermin Control: No insects/rodents present 2
14 Food worker:Clean outer clothes,effective hair restraints 43 Outer openings protected against entrance of insects/rodents 1
4 Floors: Floorcovering installed,constructed as required,good repair,clean 1
16 Food-contact surfaces designed,constructed, maintained,installed, 45 Floors graded,drained as required
located
6 Floor,wall juncture covered
17 N nfood-contact surfaces designed,constructed, maintained, 47 Mats removable,good repair,clean
stalled,located
1
8 Exterior walking,driving surfaces,good repair,clean
8 Tle service articles,storage,dispensing 2 1
19 No reuse of single service article 9 Walls,ceilings attached,equipment properly constructed,good 1
repair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed, 2
maintained,installed located 50 ustless cleaning methods used,cleaning equipment properly stored 1
Equipment&Utensils: Cleanliness 1 51 Adequate lighting provided as required 1
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors 1
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 1
27 Nonfood contact surfaces of utensils&equipment clean 1 55 Establishment and premises free of litter,no insect/rodentharborage, 1
28 Equipmentlutensils,storage,handling 1 no unnecessary articles
32 Proper disposal of waste water 1 56 Complete separation from living/sleeping quarters and laundry 1
33 Plumbing location,installation,maintenance 1 57 Clean/soiled linens stored properly 1
58 No live birds,turtles,or other animals(except guide dogs) 1
36 Toilet rooms enclosed with self-closing door 1
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean 3
entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered, 1
rodent proof,clean EfRoutine Inspection ❑Reinspection ❑ Preoperational Inspection
Other Inspection:
INSPECTOR: PERS N E: Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
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int name- �priint name X.Z- Z
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phone number title
k Page 2 of 2 plus continuation pages Focused Inspection 1/2002
Page 3 of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
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INSPECTION FORM# REMARKS
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Ma ger
Establishment: . ' S A Q.�JJ_ Inspection Date: Time: insp E[nsp
Address/City:1 '1 ' \1 r Health Dept: j L l I J (1 d.�U/ Class:-1 2 3
Based on an inspection this day,the items marked DNC identify the violations in operation orfacilities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS:Listing is not inclusive of all possible debitable items C 0 N/A DNC KEY: C[complies] NIO[not observed] NIA[not applicable]
3 DNC[does not comply] 0[other] RTE[ready-to-eat]
2
A Food workers have no exposed infected lesions/bums
2 B Personnel with infection restricted
C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultry USDA approved ` r
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonadulterated foods/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 D Personnel hands washed,clean I Proper handwash procedure
0 E Handwashing at appropriate times
0
A Hot holding greater than or equal to 14A (whole beedpork roasts 13&F.) A ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to450F. B Wounds covered adequately c
C Proper cooling C Proper sink used for handwashing 4
D Proper re-heating 0
E Proper internal cooking I consumer advisory posted SEEN
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 Adequate ❑ ishwashersanitizer ❑final rinse temp
D Proper sanitizin rocedure
B Properfood thermometerfor product E Sanitizing between raw animal origin&ready-to-eatfiood
C Thermometers appropriately placed in cooler units O
0
A Cloths and/or sponges in good repair and clean
B Wiping cloths kept in sanitizer between uses
A Produce washed
0
4� 1 —
B Raw meats not stored/prepared near ready-to-eat foods M ,
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
8 Food containers stored off the floor
0
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 foodfice 0
0 -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: 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 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 I}--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):
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
[where:
there 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- -