HomeMy WebLinkAboutFood Service Establishment Inspection 10 (3) PM
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Pdress/City:
tablishment: 's Inspection Date: Time: U.Zcs� RO[nsp RE[nsp
Cv-i [,,,j c&&j Health Dept: S . 1-0 t a L t)✓ class: 1 2 3
Based on an inspection this dAy,the items marked D C 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 0 N/A DNCI KEY: C[complies] NJO[not observed] NIA[not applicable[
60 I �ut{ d=Fblr0�r#tar • • ,M, 3 DNC[does not comply] 0[other] RTE[ready-to-eat]
� to '12 r Personnel with infection,restricted ^,
br1 bestgnaed,Alternafe sk q Food workers have no exposed infected lesions 1 burns
-'Wntfen documentat[on df tratriihg p'?,ogr m i x 2
B Personnel with infection restricted ✓
1 1#pproved=squrce,w�'gJesome, or�au#eiaife'�I, W 11C;Nt0 NI 4"
C Communicable disease of worker reported to local health director
A I Approved shellfish,finfish,meat&poultry USDA approved L 131 Handuvashinq facilitie&provided,handswashed;clean C =NIOd NIA A
B Food cans in good condition(not dented,rusty,bloated,leaking)
A Handwash facilities in all food prepldispensing&warewash areas
C WholesomeJnonadulteratedfoods!safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grownlcanned food) C Handwash facilities accessiblelconvenlent to use
E Potentially hazardous foods received at proper temperature D Personnel hands washed,clean I Proper handwash procedure
ri its' t E Handwashing at appropriate limes
Potentrallyy;hazAtdous food meets§temp011 ureerequtrgmentsf C j N10� N/A.;4. 0
] d irl rg gtdTa MmA P,jahott tlis lay,service and�treitsportatlon 15 Good=h ietiiCa radices :" r
1 a�jid' ' , 9 Y9 p Nl0i NIA '
A Hot holding greater than or equal to 1400F. (whole beeapark roasts 130'F) A ❑ No eating } ❑yNo smoking while working
B Cold holding less than or equal to 45°F. B Wounds covered adequately
C Proper cooling C Proper sink used for handwashing
D Proper re-heating 0
E Proper internalcookinglconsumeradvisoryposted24 3anitiatronxcse i of wate -cherrical) C°,, 0 NJA 2
0 A Approved sanitizeravailableladequate concentration of sanitizer
11te d�talph 0r"�o I N/0J WAI 2 s g Food-contact surfaces and utensils used for potentially
e at tetra" rat�irib,�theivnorneterseprovided a ii7 a ' I ' hazardous food sanitized at least every 4 h rs
' p f; ;TkVfk#,4 A--,W.1K t "I '&" A'''I'"``I C Adequate ❑dishwasher sarritizer TIfinal rinse temp
A Food thermometer available and accurate
D Proper sanitizin rocedure
B Properfood thermometerfor product
E Sanitizing between raw animal origin&ready-to-eat food
C Thermometers appropriately placed in cooler units
0
0 25;"'gleeri•Wr r11g oloths C N/0' 19W
!*oo to cte l°dunogt,'torage;preparat on,� - C N10� ILIA 2` �`"� "` �" �� ' " " � "
* x A Cloths and/orsponges in good repair and"clean
aYser¢�t�e..ar�dtranaprtfl r .'
�''� ''� "�'� �" B Wiping cloths kept in sanitizes between uses
A Produce washed 0
B Rawmeats not stored/prepared near ready-to-eat foods 2$ `; od�q�acs' raoesclean '4 =, • '�Nl � Nll
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 01 C Food--contact surfaces clean
F No pooling of eggs not cooked immediately 0
8 Food containers stored off the floor 30. "Hot an l'tdid wateeunder.pressurlai•provide&as require tJIO NfA h2 I l
0 38. iHandwashingaccessoriesprovided C J�UO' tWAt 1
; Fl ndiing-of,food f nmimEzed , 1; Cl; N10� NIA:r 2, A Soap!paper towels 1 drying device available
A No unnecessary handling RTE and/orcooked foods with bare hands B Dispenser(s)working: ❑Soap ❑Raper towel
B Minimize food handling,other than ready-to-eat,with bare hands C Handwash sink(s)clears/waste receptacle at handwash sink
C Adequate utensil(s)fordispensing foodlice 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[foodborne]
PHFs are hot held at: IF. 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 Fla 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 recordedilogged 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 ILyes indicate language spoken
List products cooled: by QFOIDA: *Can the QFOIDA 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 coaling 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
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
1
. ' 17x 3 4 qs a.a .a + 3i e Mr w w, ... r e w .��...� •e� ���� ��$ "0Establishment: oClnspectton: �
ddress: +?e Owner or Operator:
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served. 4 3 i Sewage disposal approved.
-Unwrapped foods not re-served -Operating as required 4
-Potentially hazardous foods not re-served
11 Toxic chemicals. 34 No cross connections,back siphonage,backflow 4 4
Stored properly,labeled properly,used properly Proper typelinstallationl backflow prevention device/air
-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
-Pesticideslrodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. 4 -Food equipment -Dish machines -Ice machines
-Well I 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]
2 Sources of food: Original container,properly labeled 0 Garbage/rubbish storage area/rooms,enclosures-properly constructed,clean
Potentially hazardous food properly thawed 2 41 Garbage/rubbish disposed of in an approved manner,at approved frequency
10 Food dispensing utensils properly stored 1 42 Vermin Control: No insectslrodenis present 2
14 Food worker,Clean outer clothes,effective hair restraints 1 43 Outer openings protected against entrance of insects/rodents 1`
4 Floors: Floor covering installed,constructed as required,good repair,clean 1
16 Food-contact surfaces designed,constructed,maintained,installed, 2 45 Floors graded,drained as required
located
46 Floor,wall juncture covered
17 Nonfood-contact surfaces designed,constructed, maintained,
L, 7 Mats removable,good repair,clean '
installed,located
8 Exterior walking,driving surfaces,good repair,clean �*
18 Single service articles,storage,dispensing '.
19 No reuse of single service article ;p
49 Walls,ceilings attached,equipment properly constructed,good
20 Dishwashing facilities approved design,adequately constructed, 2 ' repair,clean.Wall&ceiling surfaces as required Z
maintained installed located 50 Dustless cleaning methodsused,cleaning equipment properlystored
Equipment&Ulensitss Cleanliness 1 51 Adequate lighting provided as required
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
2 Wash water clean,proper temperature
53 Rooms&equipment hoods,ducts,vented as required -e
23 Accurate thermometers provided,dish basket,if used =? 54 Rooms adequate,clean,adequate lockers provided,facilities clean °1
tea
27 Nonfood-contact surfaces of utensils&equipment clean 1
55 Establishment and premises free of litter,no insect/rodent harborage, 1
28 Equipmentlutensils,storage,handling h no unnecessary articles
32 Properdisposal of waste water 1,` 56 Complete separation from living/sleeping quarters and laundry
33 Plumbing location,installation,maintenance 1 57 Clean/soiled linens stored properly 1
36 Toilet rooms enclosed with self-closing door
58 No live birds,turtles,crother animals(except guide dogs) 1
1
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toiletflxtures provided,good repair,clean '
entrance(s),smoking area indicated by sign(s)
39 Approved garbage/rubbish containers,adequate number,covered, 1
rodent proof,clean Routine inspection ❑Reinspection ❑ Preoperational Inspection
I PIE PERSON IN CHARGE: Other Inspection:
Demerit Score: *Include demerits from page 1
4 3 2 1 Total Rating
ature signature
pri nam />4XXz
print name
phone number title
DATE ORRECTIONS DUE:
�
Page 2 of 2 plus_�_ continuation pages Focused 1.sp Wi..112002
Page.3 of
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INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN ( DATE\OF INS`P`EC+TION
INSPECTION REMARKS
FORM#
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager