HomeMy WebLinkAboutFood Service Establishment Inspection 10 (4) i
Establishment: P 0k,40 Inspection Date: Ti e: 0]nsp REinsp
Address/City: ('6 Health Dept: 5 I�,n O/ : 1 2 3(9
Based on an inspection this day,the items marked DNC identify a 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 debitajitem 0 NIA DNC KEY; C fcomplies] NIO[not observed] NIA[not applicable)
3SI) allfied cr odl Oper�tdf4 � 3 DNC[does not comply] 0[other] RTE dy to-eatj
12 Pers� rlrifi#Fndtton retrcfeclE x,.,. NIO1 N1,y �. �� "A Food workers have no exposed infected lesions 1 burns
en documentat[on of tr injPersonnel with infection restricted
t l ; f`i 4
� t C Communicable disease of worker reported to local health director
A I Approved shellfish,finfish,meat&poultry USDA approved 131 [{arfdw slzimgafacDtties provided;;handswashed,clean,' C, .10 aN1A 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prepldispensing&warewash areas
C Wholesome/nonadulteratedfoods/safe B Handwash facilities in or immediately adjacent to toilet rooms
D Commercial products(no home grownicanned food) C Handwash facilities accessible/convenient to use
E Potentially hazardous foods received at proper temperature I JJ D Personnel hands washed,clean 1 Proper handwash procedure
E Handwashing at appropriate times
Potertttaily hazardousifood meets or Jim rgment N!i N!A �4 p
dbn g�slbPa $ preparafidn,dls lay;servli: aid tr:n&portatidn K� 'r 4
� m s ti � � ',R3 b k ta§'m 15! (�Oixd`l1yl@I11C�, CtIG@`Sm :{ Ci
4
A Hot holding greater than � ycxti a i s
: . - ,n .. ,or equal to 140°F. (whole beef/pork roasts A CI No eating Q No smoking while working
B Cold holding less than or equal to 450F. B Wounds covered adequately
C Proper Cooling C Proper sink used for handwashing 16,
D Proper re-heating 0
ano
E Proper internal cooking l consumer advisory posted 4,+� anitiin rinse(j,totwate �chemiCa °CI 161 NIA,
a bx as s R r Ar
pApproved sanitizeravailable/adequate concentration of sanitizer
ly a e.f c Iftl s'to� a al ts�f t (p 'NI, B Food-contact surfaces and utensils used for potentially
' � _ hazardous food sanitized at least eve 4 hours
ttt' rature,thermomsteIrs ovldt�d � every
&? v ` � C Adequate ishwashersanitizer ❑final rinse temp
A Food thermometer available and accurate
D Proper sani zin rocedure
B Proper food thermometerfor product E Sanitizing between raw animal origin&ready-to-eat food
C Thermometers appropriately placed in cooler units 41 0
p " e.:
+tl��t protected during sEog2;p at tt 1 Nb
selvtceand4��tisA A Cloths and/or sponges in good repair and clean
B Wiping cloths kept in sanitizer between uses-
A Produce washed 0
B Raw meats not stored/prepared near ready-to-eat foods 26 -pdoritae sinfaces4eieaq - 'W: +'*s 0 NIA2
C Food covered properly :� a�
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 0
8 Food containers stored off the Floor d `
clwin$err`su ,rprovrded asarequtre I 0 f193
p w" �38 Ham d*dihhil o,aC cessdries p tovidL'd�l' r a; Nfo Ilk 1
ttmg of food mtnrmtzgd / V0 21 A Soap 1 paper towels/drying device available
A No unnecessary handling RTE and/or cooked foods with bare hands B
.Dispenser(s)working: ❑Soap ❑Papertowel
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 *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[foodbcrne]
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 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 1t-M indicate language spoken
List products cooled: by QFO/DA: *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 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
.r
�• :j
Establishment t t c i 1
x .
Q
Address: Ahl L' 2 Q� (uune14 rN t
a... _:. ...__ .. ... _ :.
ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
6 Foods not re-served. 4' 31 Sewage disposal approved.
-Unwrapped foods not re-served4a
-Operating as required
-Potentially hazardous foods not re-served
34 No cross connections,back siphonage,backflow i
11 Toxic chemicals. ;
4 Proper typelinstallationlbackflow prevention device/air gap for:
-Stored properly,labeled properly,used properly -Food equipment -Hose connections -Dish machines
-Saniunn concentration not to exceed maximum permitted -Soda system carbonator -Beverage dispensers -Toilet tanks
-No unnecessary toxics on the premises -Chemical dispensers -Ice machines
-Pest icideslrodenticides properly dispensed Proper drain for:
29 Water source adequate,safe. 4 -Food equipment -Dish machines -Ice machines
-Well/well head protected from contamination Ldes
acilities. Adequate,convenient,accessible, 4
-Water quality in compliance d,properly installed
-Monitoring in compliance
OTHER ITEMS ' KEY: DNC [DOES NOT COMPLY] t
2 ourcesoffood: Original properly labeled #'
g p P Y 40 Garbagelrubbishstoragearealrooms,enclosures-propedyconstructed,clean �<
5 Potentially hazardous food properly thawed 2 41 Garbagelrubbishdisposed of in unapproved manner,at approved frequency
10 Food dispensing utensils properly stored 1 42 Vermin Control: No insects/rodents present
14 Food worker:Clean outer clothes,effective hair restraints 1 3 Ouleropenings protected againstentranceofinsectsfredents 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 _.
7 0 od-wntactsurfacesdesigned,constructed,maintained, fly.;
47 Mats removable,good repair,clean
_ips4led,located
8 Exteriorwa€king,driving surfaces,good repair,clean
18 Single service articles,storage,dispensing a2r
9 Walls,ceilingsattached,equipment prop arlyconstructed,good
19 No reuse of single service article 1
repair,clean.Wall&ceiling surfaces as required
0 Dishwashing facilities approved design,adequately constructed, ;� 1
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properly stored
Equipment&Utensils: Cleanliness 51 Adequate lighting provided as required a
1-
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 1
27 Nonfood-contact surfaces of utensils&equipment clean 1
55 Establishment and premises freeof litter,no insect/rodent harborage,
1 r
28 Equipment/utensils,storage,handling 1 no unnecessary articles
32 Proper disposal of waste water 1;, 561 Complete separation from living/sleeping quarters and laundry 1
33 Plumbing location,installation,maintenance i;, 57 Clean/soiled linens stored properly 1
58 No live birds,turtles,orother animals(exceptguide 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 entrance(s),smoking area indicated by sign(s)
3
I
39 Approved garbagelrubbish containers,adequate number,covered, 1 —
rodent proof,clean Woutine Inspection ❑Reinspection ❑ Preoperational Inspection
PERSON IN CHARGE: Other Inspection:
ECTOR: Demerit Score: *Include demerits from page 1
_7� A& 4 3 2 1 Total Rating
si ature signature
7S Z_
pin na print name Z
phone number title DATE CORRECTIONS DUE:
Page 2 of 2 plus 111 continuation pages Foe d Inspection u2002
Page3 of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
INSPECTION REMARKS
FORM#
aC l �
c'
A�ac
'L LA V VtU
s�
N --i n v-
.� YL J�
INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager