HomeMy WebLinkAboutFood Service Establishment Inspection 15 (4) � 4
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Establishment: f Inspection Date: Time: .S ROins insp
Address/City: Z Z 0/1917 ;c-i be)5 Health ept: vTA r Class: 1 2
Based on an inspection this day,the items marked DNC identify the violations in operation or facjities which must be corrected by the date specified on page 2.
RISK FACTOR ITEMS: Listing is not inclusive of all possible debitable items C NIO NIA DNC I KEY: C[complies] N10[not observed] NIA[not applicable]
60 ,,Qualtfred Food,Operator 3 DNC[does not comply] 0[other] RTE[ready-to-eat]
i' Personnel w[th:.infection restricted C
fit Designated Alternate 2 12 i+NO NIA 4
A Food workers have no exposed infected lesions!burns
€fit Written documentation of tolhllttg program y
B Personnel with infection restricted
1 Approved source,wholesorr"re,nonadulterated C 'N10 NI. i 4 C Communicable disease of worker reported to local health director
A Approved shellfish,finfish,meat&poultrUSDA approved
13 Haridvvashing.facilitiesprovtded;..hpndswashed,clean C N!0 N!A 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prepldispensing&warewash areas
C Wholesomelnonaduiterated foods/safe
D Commercial products(no home grownlcanned food) B Handwash facilities in orjre lately adjacent to toilet rooms '
G Handwash fa flities a eleo vt`nient to use
E Potentially hazardous foods received at proper temperature D Personnel h n ed,cl a !Proper handwash procedure
E HandwashinUPappropoafe times
3 P tehtrallyy'.hazardous food meets temperature;raquirements C N10 NIA 4' p
d`urmg<storage,•preparation,display, ervrae.and;•trans artation
P
15 Good ttygisn�c pract[ces
;.J C 'Wl0 NIA 2
A Hot holding greater than or equal to 140eF. (whole beeilpork roasts 130e F.) A ❑ No eating 17 No smoking while working 1/1
B Cold holding less than orequalto45 F. B Wounds covered adequately
C Proper cooling IC Pro er sink used for handwashing
D Proper re-heating
E Proper internal cooking/consumer advisory posted j24 , ` i a�,on: irtise (hot�nrater�chem calf C `Nl , A 2".
0 Approved sanitizeravailabletadequate concentration ofsanitizer
q ! Adegl,ate;fA r,hti. :ftq maintain product '" " ' " r Food contact surfaces and utensils used for potentially
w k v C 1�I0 NJA 7 B P y
r [temperature,�thermo o*Irs provided hazardous food sanitized at least every4 hours
C Adequate ❑dishwashersanitizer ❑final rinse temp
A Food thermometer available and accurate
L Proper sanitizing procedure
B Proper food thermometerfor product
E Sanitizing between rawanimal origin&ready-to-eat food
C Thermometers appropriately placed in coolerunits 0
0 025 ileettti w,prng,cloths rY t;C. NIO< NIA 1
s7a aod prostecateti i)uY ftng stgra a pre]arat(on; , ", ;C�NO[NIA �2. A lCloths and/or sponges in good repair and clean
1000,�ervicea, YT1;3i9rtportSI Pony �
A Produce washed B Wiping cloths kept in sanitizer between uses
0
B Raw meats not stored/prepared near ready-to-eat foodsact; O 6, teart ' x ,
C Food covered properly z�;.� ., �rw � x #, s ., ' x* tC ,N/p, WAS
A Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards 1 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
AZ
8 Food containers stared off the floor t3o (Hof and,coId water.under pressure,provided as required ;C NO,N/A 2
0 r38 le,lHandwashing acceasoiles provtdetl=
9 ' Handhngrof fbo`d mtnfmizedu C 00 6Z.
A Soap I paper towels I drying device available
A No unnecessary handling RTE andlorcooked foods with bare hands B
Dispenser(s)working: ❑Soap ❑Paper towel
B Minimize food handling,other than ready-to-eat,with bare hands t✓
yrI I I C Handwash sink(s)clean!waste receptacle at handwash sink
C Adequate utensil(s)for dispensing foodlice 0
4-H
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[foodbornel
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: I Is there a written illness polio that requires the food worker to report specific illness conditions
Are temperatures recordedllogged for cold holding foodslequipment? Y N and diseases to the QFD? N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N Are leftovers aved? Y N Is there a language barri r between inspector&QFO? Y N If-yes 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 qu ' ns:Name(print):
Is cooling monitored for time&temp? Y Nis the monitoring cooling recorded? Y N Indicate the title of above person I t t apply};Q DA gr Cook 0 nor FW
Obtain signature of the person h e v the QFO r nsi 'i s information at time of the
Is there a produce washing policy? Y N ♦peseribe win is washed and inspection:
where: Note: This report is wo pa form(total of 62 debitable it s) Page t of 2
sT�T {oF conlw '"Ttt u'r QEPARTI4hENT of P,(/puc HEALTH ado ' I f LA IUE M8#51f"f3 MART oRD,car os�s i
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LCLIiEALTHDEPT• %° GtJI.U�b ��1 ADDRESSICITY
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Establishment Date of=Inspection.
dress .l�%n ' 'Dr ✓u /?G � L.r/? Owner or Qperator: Ld�✓
ADDITIONAL FOUR POINT ITEMS a> 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. 4'. 4`
-Stored properly,labeled properly,used properly Pmp-eLlypelinstallation/backIlow prevention device/air gap for:
-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
-Pesticideslrodenticides properly dispensed -Chemical dispensers -Ice machines
Proper drain for:
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
;'4
-Well1 well head protected from contamination-Water quality in compliance 35 Toilet facilities. Adequate,convenient,accessible, 4
-Monitoring in compliance designed,properly installed
OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food: Original container,properly labeled L'_ 40 Garbagelrubbishstoragearea/rooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 2-' 41 Garbageirubbish disposed of in an approved manner,at approved frequency
10 Food dispensing utensils properly stored 42 Vermin Control: No insects/rodents present 2
14 Food worker:Clean outer clothes,effective hair restraints 43 Outeropenings protected against entrance of insects/rodents 1=,
4 Floors: Floor covering installed,constructed as required,good repair,clean
16 F o li ntactsurfaces designed,constructed,maintained,installed, 2'; 5 Floors graded,drained as required
toted
6 Floor,walliunclure covered
Nonfo -contact surfaces designed,constructed, maintained, 7 Mats removable,good repair,clean
alled,located
8 Exterior walking,driving surfaces,good repair,clean
�1 ingle service articles,storage,dispensing n
19 No reuse of single service article 9 Walls,ceilings attached,equipment properly constructed,good '1:
repair,clean.Wall&ceiling surfaces as required a y
20 Dishwashing facilities approved design,adequately constructed, 2. F1.
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properlystored
T3 t
Equipment&Utensils: Cleanliness 51 Adequate lighting provided as required n F
21 Preflushed,scraped,soaked and racked 52 Room free of steam,smoke odors
2 Wash waterclean,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''
271 Nonfood-contact surfaces of utensils&equipment clean 1
55 Establishment and premises tee of litter,noinsectlrodentharborage, 1
28 1 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 157 Cleanlsoifed linens stored properly 1
58 No live birds,turtles,orother animals(except guide dogs)
36 Toiletrooms 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
39 Approved garbage/rubbish containers,adequate number,covered, 1`
rodent proof,clean , outine Inspection ❑Reinspection ❑ Preoperational Inspection
P PERSO her Inspection:
Demerit Score: *Include demerits from page 1
c ' 4 3 2 1 Total Rating
signature signature
174
1
print name print name .� r
®�� ��� DATE CORRECTIONS DUE: r
phone number title
�� Page 2 of 2 plus continuation pages Focused Inspection Il2oo2
Page of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
r S
INSPECTION REMARKS
FORM#
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INITIAL(INSPECTOR) INITIAL(.PERSON IN CHARGE)
Distribution: 1st-White-Health Department 2nd-Yellow- Owner/Manager