HomeMy WebLinkAboutFood Service Establishment Inspection 95 (15) f:�S`�A'TE'',bF G�pN�VEfaTI("sflT • '�h'Q�U_S OQ'D SERVICE I�TS�_ECT14iYf?R+ �;: ilt . �-
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Establishment: id , Inspection Date: Time:
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ddresslCity: p,-50 Zvi Aj Aver Health Dept: Class: 1 z s
Based on an inspection this day,the items marked DING 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 WO NIA JDNC I KEY: C[complies] NIO[not observed] NIA[not applicable]
.;.;. .;.. :.. C[does not comply] 0[other] RTE[ready-to-eat]
60 i Quahfted Food Operator f 3
tit Designated Alternate z
12., P.erso:nnel with infection restricted NID'N1A
C
igp Written documentation of training program 2 A Food workers have no exposed infected lesions 1 burns
B Personnel with infection restricted
r1 Approved source,wholesome,none ulFerated C N/O°N/A :4`. C Communicable disease of worker reported to local health director
_ .
A Approved shellfish finfish,meat&poultry USDA approved Lr I 1 10 Handwashing fatuities provided,,fiandswashed,clean C N10 N/A 4
B Food cans in good condition(not dented,rusty,bloated,leaking) p Handwash facilities in all food prepldispensing&warewash areas
C Wholesomelnonadulteratedfoodslsafe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grown/canned food) C Handwash facilities access!blelconvenient to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean I Proper handwash procedure
0-
: ,.. ..
an was ing at appropriate times
4 entially hazardous fopif tnee�s tempelatuie`.requirements.
wring storage,preparation,display,senrioe;andtransportatiorr i
`15 'Good.hygienic:'pracficee 4` ;C<=Nlb 'NIA :2
:. .. b:
1c.
Hot holding greater than or equal to 140oF. (whore heatipork roasts 13&F) v A ❑ NO eating ❑ NO smoking while working
B Cold holding less than or equal to45°F. AB Wounds covered adequately
C Proper cooling C Proper sink used for handwashing
D Proper re-heating O
E Proper internal cooking I consumer advisory posted 4 ,. nttiWiloni'rinse�(hot water4=chemical), ;�C' Nlj.p 2
p Approved sanitizer availableladequate concentration of sanitizer
q �l\c�e Na.R,facillties�to maintain.'rcrduct ' .Y " ' x
i Q x , *prod s 5 ,C rN1,.0 N1A 2 g Food contact surfaces and utensils used for potentially
tt tefrr to µ,erryt meters• rOYi!ded:�.�-�. i F., hazardous food sanitized at least every 4 hours
r . t y..tw�re•'S .u .. a� .,. x.p a. .a .�..:a dr:s s
A Food thermometeravailableandaccurale C Adequate ❑dishwashersanitizer ❑final rinse temp
D Proper sanitizin rocedure
B Proper food thermometer for product LoE Sanitizing between raw animal origin&ready-to-eat food
C Thermometers appropriately placed in cooler units -
lo
O O i Cl n ]prn clo(hs x v
9, C iNIQ;
7 i F' d ro sct xdurin fstorag�e� Ye atattbn ° T rC'rN/O �1/ 2`
9 P P A Cloths and/ors on es in good re air and clean
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r ib>ipll,snr16e+natr� sP�rsk$tilllt P 9 9 P
B Wiping cloths kept in sanitizer between uses
A Produce washed
0
B Raw meats not storediprepared near ready-to-eat foods 26, Eoasdvcotitactsurfacescieatn k't � C
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 3.tJ.'tHofsand caltwaer:uriderpressure p[ovided as rewired ;NIA k2
O 3 nd as E 140 8:Ma w hint'a§,cd�'sgot`tes,pfovidetl ;. tJIA 1
.: k..
A Soap/paper towels/ drying device available
A No unnecessary handling RTE and/or cooked foods with bare hands
B Dispenser{s}working: ❑Soap ❑Paper towel
B Minimize food handling,otherthan ready-to-eat,with bare hands C I Handwash sink(s)clean/waste receptacle at handwash sink
C Adequate utensil(s)for dispensing food/ice O
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[potentally hazardous food], FB[foodbornel
PHFs are hot held at: F. 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 olicy that requires the food worker to report specific illness conditions
Are temperatures recordedllagged for cold holding foodslequipmen#? Y N and diseases to the Q ? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N *Are leftovers ved? Y N is there a language arrier between inspector&QFO? Y N If yes indicate language spoken
List products cooled: by QFOIDA: *Car the QFOIDA read the inspection repo> •Y N
Describe cooling methods: Indicate w o answered the above questions:Name(print):t-� s
Indicate the 'tie of above person circ a that a I �FDA Mgr Cook Owner FW
is cooling monitored for time&temp? Y N fs the monitoring of voting recorded? Y N *Obtain signal f-t person who received the QFO responsibilities information at the time of the
Is there a produce washing policy? Y N *Describe what is ashed and inspectio
where: Note: T rs a two page form(total of 62 dabitable items) Page 1 of 2
xi va �a R Date;off dhspectlpXt
4�k 0 10, V0 ! /�: �
,#ner or Aerator:
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served. TIC 31 Sewage disposal approved.
-Unwrapped foods not re-served 4
-Potentially hazardous foods not re-served -Operating as required34 ,
11 Toxic chemicals. v No cross connections,back siphonage,backflow4.;
4 Proper type/installation/backflow prevention device/air gap for:
-Stored properly,labeled properly,used properly k -Food equipment -Hose connections -Dish machines
-Sanitizer concentration not to exceed maximum permitted a
-No unnecessary toxics on the premises z. -Soda system carbonator -Beverage dispensers -Toilet tanks
-Chemical dispensers -Ice machines
-Pesticideslrodenticides properly dispensed ' Proper drain for:
29 Water source adequate,safe. 4 -Food equipment -Dish machines -ice machines `
-Well/well head protected from contamination ; ,
-Water quality in compliance 35 Toilet facilities. Adequate,convenient,accessible, 4
designed,properly installed
-Monitoring in compliance
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
27 urcesoffood: Originalcontainer,properly(abeled 40 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
5 Potentially hazardousfood properly thawed 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
10 Food dispensing utensils properly stored p1 2 Vermin Control: No insects/rodents present 2
14 Food worker:Clean outer cloches,effective hair restraints 43 Outer openings protected againstentrance of insects/rodents
4 Floors: Floor covering installed,constructed as required,good repair,clean
16 Food-contact surfaces designed,constructed,maintained,installed, 1 45 Floors graded,drained as required
led 6 Floor,wail juncture covered
7 1V food-contact surfaces designed,constructed,maintained, m 7 Mats removable,good repair,clean
installed,located -
K, 481 Exterior walking,driving surfaces,good repair,cleanL
18 Single service articles,storage,dispensing ( "
9 Walls,ceilings attached,equipment properly constructed,good 1
19 No reuse of single service article ;
repair,clean.Wall&ceiling surfaces as required v
20 Dishwashing facilities approved design,adequately constructed, ?u
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 r
22 Wash water clean,proper temperature °
W 53 Rooms&equipment hoods,ducts,vented as required t
Accurate thermometers provided,dish basket,if used 54 Rooms adequate,clean,adequate lockers provided,facilities clean 1
7 onfood-contact surfaces of utensils&equipment clean 41 � f
55 Establishment and premisesfreeof litter,noinsecthodentharborage,
8 Equipmentlutensils,storage,handling no unnecessary articles
32 Proper disposal of wastewater c 56 Complete separation from living/sleeping querters and laundry `
33 Plumbing location,installation,maintenance r ? 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 t
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at 3
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 ❑Routine Inspection ❑Reinspection ❑ Preoperational Inspection
-- Other Inspection:
-ASPEC
T R: A Demerit Score: *Include demerits from page I
4 3 2 1 Total Rating
ignature .
pntpame print N /;�d 4 f� 0
wU_6� �. 5` DATE CORRECTIONS DUE:
-phone number���- title .�
' -/ Page 2 of 2 plus continuation pages Focused Inspection 112002
Page / of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
'�LU� <
INSPECTION R.EML4RKS
FORM#
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INITIAL(INSPECTOR) r.._ INITIAL(PERSON IN C GE)
Distribution: 1st-White-Health Department 2nd-Yellow- Owner/Manager
Pagej--Of
,av
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTI N
INSPECTION REMARKS
FORM#
Ab
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J ��Z/
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01
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INITIAL(INSPECTOR) INITIAL(PERSON IN CH E
Distribution: I st-White-Health Department 2nd-Yellow- wner/Manager
Attachment 4
FOOD DESTRUCTION FORM
DATE: CryZ2/ ' w
(Firm)
9"-P
(Location)
(Town)
I have on the day of 20Y,voluntarily destroyed, or caused to be
destroyed,the food items described below. Said food items were found to be from an unapproved
source, unwholesome, adulterated or otherwise unfit for human consumption. Destruction and final
dispo �tion of said food items has been done in a manner approved by:
(Name
I hereby release the 7W ex, SG , and its members, agents, and representatives
from any and all liability.
Quantity Volume/Weight Name and Description of Reason Destroyed
Food Items
u G O
j Z�r
By:C7; y,�n I"spector's Signature /�`
Title: �/! V( 1' 4 C�..� ,_¢�-,� i�-�N
Attachment 4
FOOD DESTRUCTION FORM
DATE:
(Firm)
(Location)
by f 110 (YI4--
(Town)
I have on the J day of 20_j_b voluntarily destroyed, or caused to be
destroyed,the food ite ' ed below. Said food items were found to be from an unapproved
so rce, unwt eso e, adulterat or otherwise unfit for human consumption. Destruction and final
dis osition of said fo -item�h s been done in a manner approved by:
rmne
(N m ) owe)
I hereby release the S0u-r,4 W PbI-V , and its members, agents, and representatives
from any and all liability.
Quantity Volume/Weight Name and Description of Reason Destroyed
Food Items
y7, � ��
� 2
7
By:
pector's Sign re
Title:�st OAi rrrlu.e�u2 -� - 1