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Food Establishment Inspection Report
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As Governed by State Code Section
XXX.XXX
No. of Risk Factor/Intervention Violations
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Do Good County
No. of Repeat Risk Factor/Intervention Violations
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12344 Any Street, Our Town, State 11111
Score (optional)
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Establishment
Address
City/State
Zip Code
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License/Permit #
Permit Holder
Purpose of Inspection
Est. Type
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FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS
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Circle designated compliance status (IN, OUT, N/O, N/A) for each numbered item
Mark "X" in appropriate box for COS and/or R
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IN=in compliance
OUT=not in compliance
N/O=not observed
N/A=not applicable
COS=corrected on-site during inspection
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Compliance Status
COSR
Compliance Status
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Demonstration of KnowledgePotentially Hazardous Food Time/Temperature
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1IN OUT
Certification by accredited program, compliance
16IN OUT N/A N/O
Proper cooking time & temperatures
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with Code, or correct responses
17IN OUT N/A N/O
Proper reheating procedures for hot holding
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Employee Health18IN OUT N/A N/O
Proper cooling time & temperatures
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2IN OUT
Management awareness; policy present
19IN OUT N/A N/O
Proper hot holding temperatures
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3IN OUT
Proper use of reporting, restriction & exclusion
20IN OUT N/A
Proper cold holding temperatures
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Good Hygienic Practices21IN OUT N/A N/O
Proper date marking & disposition
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4IN OUT N/O
Proper eating, tasting, drinking, or tobacco use
22IN OUT N/A N/OTime as a public health control: procedures & records
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5IN OUT N/O
No discharge from eyes, nose, and mouth
Consumer Advisory
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Preventing Contamination by Hands23IN OUT N/A
Consumer advisory provided for raw or
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6IN OUT N/O
Hands clean & properly washed
undercooked foods
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7IN OUT N/A N/O
No bare hand contact with RTE foods or approved
Highly Susceptible Populations
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alternate method properly followed
24IN OUT N/A
Pasteurized foods used; prohibited foods not
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8IN OUT
Adequate handwashing facilities supplied & accessible
offered
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Approved SourceChemical
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9IN OUT
Food obtained from approved source
25IN OUT N/A
Food additives: approved & properly used
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10IN OUT N/A N/O
Food received at proper temperature
26IN OUT
Toxic substances properly identified, stored, & used
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11IN OUT
Food in good condition, safe, & unadulterated
Conformance with Approved Procedures
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12IN OUT N/A N/O
Required records available: shellstock tags,
27IN OUT N/A
Compliance with variance, specialized process,
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parasite destruction
& HACCP plan
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Protection from Contamination
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13IN OUT N/A
Food separated & protected
Risk factors are improper practices or procedures identified as the most
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14IN OUT N/A
Food-contact surfaces: cleaned & sanitized
prevalent contributing factors of foodborne illness or injury. Public Health
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15IN OUT
Proper disposition of returned, previously served,
Interventions are control measures to prevent foodborne illness or injury.
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reconditioned, & unsafe food
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GOOD RETAIL PRACTICES
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Good Retail Practices are preventative measures to control the addition of pathogens, chemicals, and physical objects into foods.
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Mark "X" in box if numbered item is not in compliance
Mark "X" in appropriate box for COS and/or R
COS=corrected on-site during inspection
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COSR
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Safe Food and WaterProper Use of Utensils
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28
Pasteurized eggs used where required
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In-use utensils: properly stored
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29
Water & ice from approved source
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Utensils, equipment & linens: properly stored, dried, & handled
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Variance obtained for specialized processing methods
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Single-use & single-service articles: properly stored & used
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Food Temperature Control44
Gloves used properly
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Proper cooling methods used; adequate equipment for
Utensils, Equipment and Vending
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temperature control
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Food & non-food contact surfaces cleanable,
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Plant food properly cooked for hot holding
properly designed, constructed, & used
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Approved thawing methods used
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Warewashing facilities: installed, maintained, & used; test strips
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Thermometers provided & accurate
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Non-food contact surfaces clean
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Food IdentificationPhysical Facilities
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Food properly labeled; original container
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Hot & cold water available; adequate pressure
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Prevention of Food Contamination49
Plumbing installed; proper backflow devices
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36
Insects, rodents, & animals not present; no unauthorized persons
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Sewage & waste water properly disposed
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37
Contamination prevented during food preparation, storage & display
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Toilet facilities: properly constructed, supplied, & cleaned
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38
Personal cleanliness
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Garbage & refuse properly disposed; facilities maintained
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39
Wiping cloths: properly used & stored
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Physical facilities installed, maintained, & clean
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40
Washing fruits & vegetables
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Adequate ventilation & lighting; designated areas used
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Person in Charge (Signature)
Date:
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Inspector (Signature)
Follow-up:
YES
NO
(Circle one)
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