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<br />
<br />~ '.
<br />
<br />Est.
<br />1.0.
<br />[1-10)
<br />
<br />Owner Name:
<br />Address:
<br />
<br />Establishment Name:
<br />
<br />Food Service Establishment
<br />Inspection Report'
<br />
<br />
<br />Based on all inspection this day, the Itams circled below ldentlly the vlolatlbns In operations or lacllltles which must be COmlCted by
<br />the next routine Inspection or such shorter period 01 time as may be specllled In writing by the regulatory authortty, Fallura to comply
<br />with any tlma limits lor corrections specified In this notice may reault In cessation 01 your Food Service operations,
<br />ITEM
<br />WT, eOl, NO, WT, eOl,
<br />
<br />PURPOSE
<br />
<br />Regular '" , , " >>,
<br />FOllOW-Up ,""" 2
<br />Complaint ".",,3
<br />Investigation "'" 4
<br />Other ,"',"'," 5
<br />
<br />ITEM
<br />NO,
<br />
<br />
<br />
<br />Source; soun" condition, no spoilage
<br />Q2 Original container: pro~rty labeled
<br />
<br />FOOD PROTECTION
<br />
<br />I 'OS Potentially hazardous lood meets temperature rtlQuirements 5 32
<br />during Slorage, preparation, display, service transportation
<br />.04 FacilitIes to maintain product temperature 4 3:
<br />D51 Thermometers provided and conspicuous , 34
<br />01 Potentially hazardous food properl, tnawed 2 35
<br />'07 Unwrapped and potentially hazardous lood not re-served 4 38
<br />01 Food protection during storage, preparation, display, 2 37
<br />service. transportation
<br />. Handling 01 lood (ice) minimized 2 38
<br />10 In use, lood (ice) dispensing utensils properly stored 1 39
<br />
<br />PERSONNEL
<br />
<br />." Personnel with inlectlons restricted 5 40
<br />"2 Hands washed and clean, good hygienic practices 5 4'
<br />13 Clean clothes, .halr reslraints 1 42
<br />
<br />FOOD EQUIPMENT & UTENSILS
<br />
<br />14 Food (ice) contact surfaces: designed, constructed, maln- 2 43
<br />I!lined, installed. localed
<br />15 Non-food contact surfaces: designed, constructed, main- 1 44
<br />tained, installed, located
<br />1. Oishwashing lacilllies: designed, conslrucled, maintained. 2 4S
<br />'nstalled. loealed, operaled
<br />17 Accurate thermometers, chemical test kits provided, !!auge 1 48
<br />cock (v." IPS valve)
<br />11 Pre-lIushed. scraped, soaked ' , 47
<br />1. Wash, rinse waler: clean, proper temperature 2 C8
<br />'20 Sanitization rinsp.' clean, temperature, concentration, ex- 4 48
<br />posure time; equipment, utensils sanitized
<br />21 Wiping clolhs; ciean, use' restricted 1 50
<br />22 Food-contacI surfaces 01 equipment and utensils clean. 2 51
<br />Iree 01 abrasives, detergents
<br />23 Non-Iood contact su.rfaces 01 equipment and utensils clean 1 52
<br />24 Storage, handling 01 clean equipmentl utensils 1 53
<br />as Single-service articles. storage. dispenslhg 1 54
<br />. No re-use of single service articles 2 55
<br />
<br />WATER
<br />
<br />
<br />'%7 Watllr source, sale: hot & cold under pressure
<br />
<br />RATING SCORE 75-77
<br />
<br />100 less weight 01 [[]]
<br />Items vlolaled ...
<br />
<br />FOLLOW-UP
<br />
<br />ACTION
<br />Change,78-C
<br />Delete, , , , 0
<br />
<br />Yes , , , , , , 74-1
<br />No ......,..,2
<br />
<br />.Culleal l1ems ReQu,ring Immediate Atlentlon,
<br />
<br />Remarks on back 180-1)
<br />
<br />::-.......... ,.. '" C'.,
<br />
<br />Page ~of.2L
<br />
<br />ZJp
<br />
<br />SEWAGE '
<br />[::!J Sewage and waste water disposal
<br />
<br />~
<br />
<br />
<br />
<br />Instelled, maintained
<br />.. Cross-connection, back siphonage, baCkllow
<br />
<br />TOILET &: HANDWASH!NG FAC!LITIES
<br />
<br />011 , Number, cen~enient, aceessilllE, ,:l(!~igned. Instslled
<br />
<br />Toilet roem! enclosed, sel!'~losir.. doors, fixturtls, good
<br />3Z repair, eleen: hand e!aanser, rsnilpr.... to_l.!tis.un/h.nd.
<br />drvin,; devices provided, proP_I ..~.Te reccPUoCI"
<br />
<br />.. 80
<br />
<br />2 11
<br />
<br />GARBAGE & REFUSE DISPOSAL
<br />
<br />IS Conlainers or receptacles, covered: adequate number I I 82
<br />insectl rodent prOOI. Irequency, clean
<br />14 Outside storage area enclosures properly conslructed, I ' 13
<br />clear.; conlrolled incineralion
<br />
<br />INSECT, RODENT, ANIMAL CONTROL
<br />
<br />
<br />.. Presence o! i,.,sects/rodents - ouler ooenin"s prolecled,
<br />no birdS, lurtles, other animals
<br />
<br />FLOORS, WALLS & CEILINGS
<br />
<br />. Floors, constructed, drained, clean, good repair, covering 1 IS
<br />inslallalio~, duslless cleaning methods
<br />31' Walls, ceiling, allaclled equipmenl: construcla.:!, good , III
<br />repair. clean, surtaces. dustless cleaning mel"ods
<br />
<br />LIGHTING
<br />
<br />
<br />. lighting provided as required, IIxtures shIelded
<br />
<br />VENTILATION
<br />
<br />~ Rooms and equipment - vented as required
<br />
<br />c:!2]
<br />
<br />DRESSING ROOMS
<br />
<br />
<br />40 Rooms clean, lockers provided, facilities clean, located
<br />
<br />OTHER OPERATIONS
<br />
<br />'41 Toxic items p.operly stored, labeled. used I 70
<br /> Premises maintained Iree of liller, unnecessary anicles,
<br />G cleaning,maintenance equipment properly stored, Author- 1 7'
<br /> ized personnel
<br />a Complete separation Irom living! sleeping Quarters, Laundry, 1 72
<br />.. Clean, soiled linen properly stored 1 73
<br />
<br />Received by: name
<br />
<br />tllle
<br />
<br />Inspected by: name
<br />
<br />lille
<br />
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