HomeMy WebLinkAboutFood Service Establishment Inspection 85 (11) t
SIMON
Establishment: zuiar A!-- iz Inspection Date: , Time: !� tnsp Rt:ins
Address/City: PSG j7 t4/ ?Z_1 re- Mealth Dep:
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 N10 NIA DNC I KEY: C[complies] NIO[not observed] NIA[not applicable]
DNC[does not comply] 0[other] RTE[ready-to-eat]
,60w QuaO(jied Po d Operator p .r 3
124i?ersannet WrtFin[ettro. reslct�t ,k �., , C Nl0` NlAvfi
6 gtnated Alfernae Food workers have no exposed infected lesions 1 burns
2 Written documentation,af tralnfn program it
B Personnel with infection restricted
9 �Apprwop source,whoiesome;non a s a 6NIO NlA 4 C Communicable disease of worker reported to local health director
d — - -
A I Approved shellfish,finfish,meal&poultry USDA a roved '13 :RO W#q hmq fac l[ttes provided;liandsxvrasfled,c[eaj ,' C IN'NIA 4
B Food cans in good condition(not dented,rusty,bloated,leaking) A Handwash facilities in all food prep/dispensing&warewash areas
C Wholesome/nonaduIterated foods/safe B Handwash facilities in or immediately 4djacent to toilet rooms ,C
D Commercial products(no home grown/canned food) C Handwash facilities accessible/corwient to use
E Potentially hazardousfoods received at proper temperature D Personnel hands washed,clean/Pr Uandwash procedure
E Handwashmg at appropriate times
3 "Potentraily,hazartlojts'footlmeets temperature requ'rem�nts"'I C Nj NIA ;4`
during storage,preparation,,'display,service arfd�transportation ., a;Y9 -p v C ,N1Ni ocd h le[llCe ractices � rra y �.k ,�
_. .. ' .:
A Hot holding greater than or equal to 140°F. (whose aearrPo roasts Aso°F.) ❑ No eating ❑ No smoking while working
B Cold holding less than or equal to 45°F. B Wounds covered adequately
C Proper cooling C I Proper sink used for handwashing
D Proper re-heating 0
2 Sanitiz , 91
¢E Proper internal cooking lconsumer advisory posted t &WJ
p A Approved sanitizer available/adequate concentration ofsanitizer
Ade u yfe facilities t`or maintain product':,° C N10 NIA! 2i B Food-contact surfaces and utensils used for potentially
" '° '' - hazardous food sanitized at least every 4 hours
eTatur;;thermometers 3prpvg00� � � �ab, , � ,
A Food thermometer available and accurate C Adequate ❑tlishwashersanitizer ❑fine]rinse temp
L Proper sanitizin rocedure
B Properfood thermometerfor product E Sanitizing between raw animal origin&ready-to-eat food
C Thermometers appropriately placed in cooler units A 0
CEean:wpingc[gths C ](( A-
41F.oglpo>tctt<d dtfring storage,,pFepii; ([ N!Q N Cloths and/or sponges in good repair and clean
A tdispiay seribice and transpbr�atl n - v g PAd I
.K'5-� a � '' ft ,2.A, � � B Wiping cloths kept in sanitizer between uses
A Produce washed 0
B Raw meats not storedlprepared near ready-to-eat foods ;2 A-0,60 tact's"F faces ct an C l�
C Food covered properly AAz Food equipment clean,utensils clean,equipment interiors clean
D Adequate splash guards 1 sneeze guard A 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
$
` kx t 'A i� sk
8 Food containers stored offihefloor �36 1,H�bhhd cold water under pre§sure, ilovided,asirequire ? ;Ni 2
—60"
w g P, ,. , . N/® 1e 3 vHandwashm aacesories rgvided
N/A
r No unnecessary handling RTE anidlorcooked foods I C7 �2 Soap!paper towels I drying device available
ods with bare hands B
Dispensers}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)fordispensing food/ice pi --H
fl eiD SL *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 FB illness are ou required to report to the local health department?
Roasts Other
Describe re-heating procedures: Is there a written illness policy th requires the food worker to report specific illness conditions
Are temperatures recordedllogged for cold holding f dslequipment? Y N and diseases to the QFO? Y *Do you have a paid sick leave policy? Y N
Are foods cooked in advance and cooled? Y ♦Are leftovers saved? Y N. Is there a language barrier etween inspector&QFO? Y N If ves indicate language spoken
List products cooled: by QF01DA: // *Can the OF01DA 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 Pe person wh receiv the QFO r sponsibililies information at the time of the
Is t ere a produce washing polic 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
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ADDITIONAL FOUR POINT ITEMS KEY: DNC [DOES NOT COMPLY]
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6 Foods not re-served.
4 31 Sewage disposal approved. �4
-Unwrapped foods not re-served
-Potentially hazardous foods not re-served -Operating as required
No cross connections,back siphonage,backflow
I 1 Toxic chemicals. 4 Proper typelinstal ationl backflow prevention device/air gap for: 4.
-Stored properly,labeled properly,used properly -Food equipment -Hose connections -Dish machines
-No nn- u concentration not to exceed maximum permitted -Soda system carbonator -Beverage dispensers -Toilet tanks
-No unnecessary toxics on the premises -Chemical dispensers -Ice machines
-Pesticideslro den ticides properly dispensed Proper drain for:
29 Water source adequate,safe. 4', -Food equipment -Dish machines -Ice machines
-Well lwell 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 1 40 Garbagelrubbish storage arealrooms,enclosures-properly constructed,clean
5 Potentially hazardous food properly thawed 2 41 Garbagelrubbish disposed of in an approved manner,at approved frequency }:
od dispensing utensils properly stored 1 : 42 Vermin Control: No insects/rodents present .
�14 F d worker:Clean outer clothes,effective hair restraints 1 43 Outeropenings protected againstentrance of insectslrodents 1
loors: Floor covering installed,constructed as required,good re i,clean i
16 f od-contact surfaces designed,constructed, maintained,installed, 45 Floors graded,drained as required
located
6 Floor,wall juncture covered
17 Nonfood-contact surfaces designed,constructed, maintained, 47 Mats removable,good repair,clean
tatted,located 1$ gle service articles,storage,dispensing 1
4$ Exterior walking,driving surfaces,good repair,clean
-'
49 Walls,ceilings attached,equipment properly constructed,good 1
9 No reuse of single service article F
repair,clean.Wall&ceiling surfaces as required
20 Dishwashing facilities approved design,adequately constructed, 2
maintained installed located 50 Dustless cleaning methods used,cleaning equipment properlystored 1<
Equipment&Utensils Cleanliness 1 51 Adequate lighting provided as required
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
2 ccurate thermometers provided,dish basket,if used
4 Rooms adequate,clean,adequate lockers provided,facilities clean
27 fifood-contact surfaces of utensils&equipment clean 1
5 Establishment and premises free of litter,no insect/rodent harborage,
27 EquipmenUutensils,storoge,handling no unnecessary articles _
32 Proper disposal of wastewater 1 56 Complete separation from livinglsleeping quarters and laundry
33 Plumbing location,installation,maintenance 1 57 Cleanlsoiled linens stored properly �;
Psi
58 No live birds,turtles,orotheranimals(except guide dogs) r W
36 Toilet rooms enclosed with self-closing door 1 r
59 Seats 75 or more:Nonsmoking area provided,sign(s)posted at
37 Proper toilet fixtures provided,good repair,clean enirance(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
Other Inspection:
PERSON IN CHARGE: Demerit Score: *Include demerits from page I
4 3 2 1 Total Rating
signatur� s{ tur g G I
pri t name
print name
�� - DATE CORRECTIO S DUE:
phone number title
Page 2 of 2 plus continuation pages Focused Insgectlon 111101
L Page of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE OF INSPECTION
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INSPECTION REMARKS
FORM#
0 A-01
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INITIAL(INSPECTOR) INITIAL(PERSON IN CHARGE)
Distribution: Ist-White-Health Department 2nd-Yellow-Owner/Manager
Pag of
INSPECTION REPORT STATE OF CONNECTICUT
FOOD SERVICE ESTABLISHMENTS DEPARTMENT OF PUBLIC HEALTH
CONTINUATION SHEET
NAME OF ESTABLISHMENT TOWN DATE O INSPECTION
INSPECTION REMARKS
FORM#
4
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TIAL(INSPECT R) INITIAL(PERSON IN CHARGE)
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Distribution: 1st-White-Health Department 2nd-Yellow-Owner/Manager