HomeMy WebLinkAboutFood Service Establishment Inspection 46 (8) Establishment: / Inspection Dater Time: R0I E[ns
Address/City: {j( �L�Gt�cJl �✓.-ScK Class: 1 2 3t
Based on an inspection this day,the items marked DNC 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 NIO NIA NCI KEY: C[complies] NIO[not observed] NIA[not applicable]
G4� lttahhed FoodsOperator 3 DNC[does not comply) 0[other] RTE[ready-to-eat]
�.« 72. ,s�erSOnnel With lnf2C`ti01,�6strIct0d, r Cr Nl�' A 4�
D0.es�gndfedAlternate • 2 s a 3 ,
W ritten documentation training�rogFar A Food workers have no exposed infected lesions 1 burns
B ,of � ,
B Personnel with infection restricted
' C N1A ppro ;Aved source m,wholesome,nonadulfera'}ed, N10 t a C Communicable disease of worker reported to local health director
A Approved shellfish finfish,meat&poultry USDA approved A- Handwas in faG htte, p ovtdect a washed clean C� WO IN �4"'
B Food cans in good condition(not dented,rusty,bloated,leaking) g` reas `° s 4
A Handwash 'lilies in all food pr 1 i ensin &warew areas
C Wholesomelnonadulteratedfoods/safe B HandwA acilities in or t dI4 0 nt to set rooms
D Commercial products(no home grown/canned food) C Hand fa It t c s' 1 lc n e&
E Potentially hazardous foods received at proper temperature D Pets nel h le wash procedure
E Handwashing at appropriate times
1 Potoi tlali .hazardous food meets temperature rdgb!O' tens- ;C N10!N/ ,4 O
� dur)�g a�orage;preparation„displpy,servrc��nd�,tfartspoctation,; ,,� �� ,h ,n ,
M 15 Good hygie'nrcprctie,°s� Q< tK.2
A _Hot holding greater than or equal to 140 F (whole beeflpadc masts 1300F.) A ❑ No eating ❑ No 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 yC 0
u x,
E Proper internal cookinglconsumeradvisoryposted 4 Sanrtizationwr[r.0e�(Fiot va(�r chernical) `C N(V,
0 Approved sanitizeravaiiableladequate concentration of sanitizer
4 ry Adequate,facilitiesto maintaln<produotC pypwg2 B Food-contact surfaces and utensils used for potentially
; tQrr erature,xthermometers prov[detl � ,� x-��-a-� hazardous food sanitized at least every 4 hours dC
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A Food thermometer available and accurate C Adequate ❑dishwashersanitizer ❑final rinse temp
AL
D Proper sanitizin rocedure
B Proper food thermometer for product lk E Sanitizing between raw animal origin&ready-to-eat food
C Thermometers appropriately placed in cooler units
0
s 25 Clean vviprn� idttta a#
opd protected:during storage,preparation, *�� V NIQ 1t
f a drs l y,ser�l,6 and transporfattor $ �, A Cloths and/or sponges in good repairand clean
A :Produce washed B Wiping cloths kept in sanitizer between uses
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B Raw meats not stored/prepared near ready-to-eat foods XI r26� o{rc conf stit:faees-clean " '
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
8 Food containers stored off the floor Or` of aild` raerindsr pressure,�provrded ashrequireii C "N( ' h
O 38 aAd paphing acce§rynegs�prrdvrded g �E r c IN q
k andil ofJo minimized C 7 .N! s:, . .. F
_� g � _Boa 1 paper towels l 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,other than ready-to-eat,with bare hands y[ C Handwash sink(s)clean 1 waste receptacle at handwash sink
C Adequate utensil(s)for dispensing 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 foods,FS[foodborne)
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 F illness are you required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illnes policy that requires the food worker to report specific illness conditions
Are temperatures recordedliogged for cold holding foodslequipmenYY N and diseases to the 0? Y N *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y N Are left ers saved? Y N Is there a languag barrier 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 questions:Name(print):
Indicate the title of above person(circle all that apply):QFO DA Mgr Cook Owner FW
m Is cooling monitored for time&temp? Y N Is the storing of cooling recorded? Y N .Obtain signature of a pers n r _-bltities m motion at th%time of the
Is there a produce washing policy? Y N *De s ibe what is washed and inspection:
where: Note: This report Is a two page form(total of 62 debitable items) Page 1 of 2
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ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY) U 'i�J
6 Foods not re-served. t r
-Unwrapped foods not re-served 4 31 Sewage disposal approved.
-Potentially hazardous foods not re-served ; -Operating as required R
No cross connections,back siphonage,backfiow
11 Toxic chemicals. �4" Proper l a in IIpreventiondevice/
-Stored properly,labeled properly,used properly '
-Food equipment -Hose connections -Dish machines
-Sanitizer concentration not to exceed maximum permitted k -Soda system carbonator -Beverage dispensers -Toilet tanks
-No unnecessary toxics on the premises -Chemical dispensers -Ice machines
-Pesticides/rodenticides properly dispensed Proper drain for: a.
29 Water source adequate,safe. -Food equipment -Dish machines -Ice machines
tell
-Well!well head protected from contamination �_R 35 Toilet facilities. Adequate,convenient,accessible, 4 w
-Water quality in compliance -_
-Monitoring in compliance designed,properly installed ;
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OTHER ITEMS KEY: DNC [DOES NOT COMPLY]
2 Sources of food:Original container,properly labeled 40 Garbage/rubbish storage arealrooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 1" 41 Garbagelrubbish disposed of in an approved manner,at approved frequency
10 Food dispensing utensils properly stored 42 Vermin Control: No insectslrodents present '$
14 Food worker:Clean outer clothes,effective hair restraints 1.1 43 Outer openings protected against entrance ofinsects!rodents
4 FOdry Floor covering installed,constructed as re ui ,goad pair,cle "1
16 Food-contactsurfaces designed,constructed,maintained,installed, 45 Floors graded,drained as required ;
XA
catetl 6 Floor,wall juncture covered
nfood-contact surfaces designed,constructed,maintained, '
installed,located o 7 Mats removable,good repair,clean
48 Exterior walking,driving surfaces,good repair,clean1
1$ Single service articles,storage,dispensing -
" 9 all ,ceilings attached,equipment properly constructed,good
19 No reuse of single service article .�;A � <
20 Dishwashing facilities approved design,adequately constructed, k�'' air,clean.Wall&ceiling surfaces as required
maintained instated located ( 5 stlesscleaningmethodsused,cleaningequipmentproperlystored
Equipment&Utensils�_Gteanlinass 51 Adequate lighting provided as required
21 Preliushed,scraped,soaked and racked 52 Room free of steam,smoke odors
22 Wash water clean,proper temperature E 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 premisesfreeof litter,noinsectlrodentharborage,
28 Equipmentlutensils,storage,handling
i , no unnecessary articles _
32 Xroper disposal of waste water _;} 56 Complete separationfrom livingisleeping quarters and laundry Lit
33 Plumbing location,installation,maintenance 57 Clean/soiled linens stored properly
58 No live birds,turtles,orother animals(except guide dogs)
36 Toilet rooms enclosed with self-closing door
59 Seats 75 ormore:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean a
entrance(s),smoking area indicated by sign(s)
,Y
39 Approved garbage/rubbish containers,adequate number,covered,
rodent proof,clean Proutine inspection ❑Reinspection ❑ Preoperational Inspection
Other Inspection:
INSPECT R: PERSON IN CHARGE: Demerit Score: *Include demerits from page I
t� 4 3 2 1 Total Rating
nature signature /
print name print name
le DATE CORRECTIONS DUE:
phone number � .� title
� Page 2 of 2 plus continuation pages Focused Inspection 12002
')OV, Page4'ofc�_
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSP CTION
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INSPECTION FORM REMARKS
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INITIAL(INSPECTOR) INITIAL(PERSON IN C
1 Distribtfion: 1st-White-Health Department 2nd-Yellow- Owner/Manager
Page 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 INSP CTION
4 ( /
INSPECTION
MAS
FORM#
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INITIAL(INSPECTOR) 7
INITIAL(PERSON IN CH
Distribution: I st-White-Health Department 2nd-Yellow- 0wner