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Home My WebLink AboutFood Service Establishment 100 Evergreen ° STATE OF CONNE(�}PICU OQb LvR t" d R+ DEAARTINEN BLIC Establishment: 'S Inspection Date: Time: (7_ ROinsp [ sp Address/City: 0 W Health ept: w. v, . 2 4 Based on an inspection this y,the items marked DN identify 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 NIO WA DNC KEY: C[complies] NIO[not observed] NIA[not applicable] 60 Qualified Food Operator 3 DNC[does not comply] 0[other] RTE[readydo-ea 61 Designated Alternate 2 12° Personnel with infection restricted N10 4 62 Wriften documentation of training program 2 A Food workers have no exposed infected lesions!burns ,/ B Personnel with infection restricted 1 Approved source,wholesome,nonadulterated C !0 NIA '4 C Communicable disease of worker reported to local health director A Approved shellfish,finfish,meet&poultry USDA approved 131 Handwashing#acilitiesprovided, hands washed,clean C' Nl N/A 4 B Food cans in good condition(not dented,rusty,bloated,leaking) ✓ A Handwash facilities in all food prep/dispensing&warewash areas C Wholesomelnonadulteratedfoods!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 E Handwashing at appropriate times 3 Potentially hazardous food meets temperature requirements C' 0 NIA 4 p during storage,preparation,'display,service and transportation 15 Good hygienic practices C 6NINIA 2 A Hot holding greater than or equal to 140°F. (whore beef/pork roask 1300F) A ❑ No eating 0 No smoking while working B Cold holding less than or equal to 45°F. B Wounds covered adequately C Proper cooling V C Proper sink used for handwashing D Proper re-heating E Proper internal cooking/consumer advisory posted 24 Sanitization rinse.(hot water-chemical) C C6 NIA 2 0 A Approved sanitizeravailableladequate concentration ofsanitizer 4 Adequate facilities to maintain product G N!0 NIA 2 S Food-contact surfaces and utensils used for potentially temperature,thermometers provided hazardous food sanitized at least every 4 hours A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp Proper sanitizing B Proper food thermometer for product D -� C Thermometers appropriately placed in cooler units E Sanitizing between raw animal origin&ready-to-eat food 0 025 Clean,wiping cloths CE13 NIA 1 7 Food,protected during,storage,preparation, C Nl N!A 2.display,service and'transportation A Cloths and/or sponges in good repairandclean , B Wiping cloths kept in sanitizer between uses ✓ A Produce washed cY O B Raw meats notstoredlprepared near ready-to-eat foods f✓ 26 'Food=lcontact.surfaces,clean c NI . NIA 2 , ri u f C Food covered properly v A Food equipment clean,utensils clean,equipment interiors clean f D Adequate splash guards I 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 IZZ 8 Food containers stored off the floor 30 ,Hot and cold water'under pressure,provided as required C W NIA 2 0 38:Handwashing accessories provided C NIA 1 ,9 : Handling of food.m,inimized C 1 WA 2 A No unnecessary handling RTE and/or cooked foods with bare hands A Soap I paper towels!drying device available V 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 utensils)for dispensing food/ice 0 0 -DESCRIBE DEFICIENCIES ON CONTINUATION SHEETS The following information is not debitable and does not affect your score. AEY: 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 reheating procedures: Is there a written illness policy that requires the food worker to report specific illness conditions Are temperatures recordedllogged for cold holding foodslequipment? 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 Ifs indicate language spoken List products cooled: by QFOfOA: *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):OFO 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 r1is there a produce washing policy? Y N ♦Describe what Is washed and inspection: ere: Note: This report is a two page form(total of 62 debitable items) Page 1 of 2 i k mentbsish r a saf't�e' o0��a lnx spae mc f..i.o- a Establ r � Address ° i r - r or�0 erafdr: icy, , A „ ,. w . �.� p '' 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 No cross connections,back siphonage,backflow 11 Toxic chemicals. ti 4' Propertypelinsta lationt backflow prevention device/air gap for; -Stored properly,labeled properly,used properly -Food equipment -Hose connections -Dish machines t{ -Sanitizer concentration not to exceed maximum permitted -Soda system carbonator -Beverage dispensers -Toilet tanks k. -No unnecessary toxics on the premises . -Chemical dispensers -Ice machines ' -Pesticideslrodenticides properly dispensed a., Proper drain for: 29 Water source adequate,safe. �4 -Food equipment -Dish machines -Ice machines ' b -Well/well head protected from contamination f 35 Toilet facilities. Adequate,convenient,accessible, e4 -Water quality in compliance -Monitoring in compliance _4 designed,properly installed OTHER ITEMS KEY: DNC [DOES NOT COMPLY] t m 2 Sources of food:Original container,properly labeled 40 Garbage/rubbish storagearealrooms,enclosures-properly constructed,clean .. �f 5 Potentially hazardous food properly thawed 2 41 Garbage/rubbish disposed of in an approved manner,at approved frequency :a 10 Food dispensing utensils properly stored 42 Vermin Control:No insects/rodents present 2 14 Food worker:Clean outer clothes,effective hair restraints 1 x 43 Outeropenings protected againstentrance of insectslrodents 5 4 Floors: Floor covering installed,constructed as required,good repair,clean . 16 Food-contact surfaces desi designed,constructed,maintained,installed, fi i r 9 r2.i 5 Floors graded,drained as required r-� located 'A 46 Floor,wall juncture covered r � 17 Nonfood-contactsurfaoes designed,constructed,maintained, 1 7 Mats removable,good repair,clean t installed,located � 1: 8 Exterior walking,driving surfaces,good repair,clean ; 1$ Single service articles,storage,dispensing 0 49 Walls,ceilings attached,equipment properly constructed,good 19 No reuse of single service article 2F, t : repair,clean.Wall&ceiling surfaces as required 20 Dishwashing facilities approved design,adequately constructed, 0l H maintained installed located f 50 Dustless cleaning methods used,cleaning equipment properly stored Equipment&Utensils: Cleanliness 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,p rope r 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 1 55 Establishment and premises free of litter,no insect/rodent harborage, 28 Equipmentlutensils,storage,handling 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 57 Cleantsoiled linens stored properly 58 No live birds,turtles,or other animals(exceptguida dogs) 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 entrance(s),smoking area indicated by sign(s) 39 Approved garbage/rubbish containers,adequate number,covered, rodent proof,clean ORoutine Inspection einspection 0 Preoperational Inspection INS ECTOR: PERSON IN CHARGE: Other Inspection: Demerit Score: *Include demerits from page 1 4 3 2 1 Total Rating s' nature signs ure �� pri i name print name � — DATE CORRECTIONS DUE: phone number title �C Page 2 of 2 plus continuation pages Focused Inspection 1/2002 Page. of-5 INSPECTION REPORT STATE OF CONNECTICUT FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH CONTINUATION SHEET NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION LA ` s i 1 S. 14v( � INSPECTION REMARKS rF�ORM# V L �P 0 -- P ✓ ' �V o� v� INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE) Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager