Risk Category _____________________ Number of meals _____________________ RETAIL FOOD ESTABLISHMENT INSPECTION REPORT Reinspection Required o Yes o No on/after ______________ Return CIVCS Form o Yes o No return by ______________ Based on an inspection this day, items marked as "OUT" below identify the violations which must be corrected by the next routine inspection or such shorter period of time as may be specified by the regulatory authority. Failure to comply with any time limits for corrections specified in this notice may result in revocation or suspension of your retail food license. ESTABLISHMENT: OWNER: ADDRESS: LICENSE/DOR #: CITY, STATE, ZIP: DATE: INSPECTION TYPE: Regular Follow-Up CRITICAL VIOLATIONS These items are related to foodborne illness a. Original container, properly labeled b. Food protected from contamination 10 EQUIPMENT DESIGN, CONSTRUCTION a. Food-contact surfaces b. Nonfood-contact surfaces a. Refrigeration units provided with accurate, conspicuous thermometer b. Dishmachine provided with accurate thermometer & gauge cock c. Chemical test kits provided, accessible 12 CLEANING OF EQUIPMENT AND UTENSILS a. Food-contact surfaces b. Nonfood-contact surfaces c. Dishwashing operations d. Wiping cloths 13 UTENSILS, SINGLE-SERVICE ARTICLES a. Utensils provided, used, stored b. Single-service articles stored, dispensed, used c. No reuse of single-service articles 03 FOOD TEMPERATURE CONTROL Rapidly cool food to 41° F or less (FBI) Rapidly reheat to 165° F or greater (FBI) Hot hold at 135° F or greater (FBI) Required cooking temperature (FBI) Cold hold at 41° F or less (FBI) Food thermometer (probe-type) Adequate equip. to maintain food temps. (FBI) 14 PHYSICAL FACILITIES a. b. c. d. e. Plumbing: installed, maintained Garbage and refuse Floors, walls, ceilings Lighting Ventilation f. Locker rooms g. Premises maintained h. Separation of living, laundry i. Restroom facilities 15 OTHER OPERATIONS a. Personnel: clean clothes, hair restraints, authorized b. Linen properly stored 04 SANITIZATION a. Manual b. Mechanical c. In-place Quat-Ammonium Other___________________________ 05 WATER, SEWAGE, PLUMBING SYSTEMS a. b. c. d. c. Dishwashing facilities 11 TESTING DEVICES a. Personnel w/infections restricted (FBI) b. Wounds properly covered c. Hands washed as needed (FBI) d. Hygienic practices (FBI) e. Smoking, eating, drinking f. Demonstration of knowledge g. Preventing food contamination from bare hands (FBI) Chlorine These items can lead to critical violations if not corrected 09 FOOD LABELING, FOOD PROTECTION 02 PERSONNEL Sanitizer: NON-CRITICAL VIOLATIONS IN OUT N/A N/O a. Approved source (FBI) b. Wholesome, free of spoilage c. Cross-contamination (FBI) d. HACCP plan e. Date marking f. Consumer advisory (7/1/13) a. b. c. d. e. f. g. INSPECTION TIME: Start_______________________ Other____________________ Duration____________________ Complaint/FBI 01 FOOD SOURCE TCHD ID#: Safe water source Hot & cold water under pressure Backflow, backsiphonage Sewage disposal Water: ______________________ Sewer: _____________________ HACCP Plan/Time Temp Control Plan: o Enforcement actions: o Voluntary Closure o Embargo o Voluntary Condemnation COMMENTS: 06 HANDWASHING a. Adequate number, location (FBI) b. Accessible (FBI) c. Soap & drying devices available (FBI) 07 PEST CONTROL a. Evidence of insects or rodents b. Pesticide application c. Animals prohibited KEY: "IN" - Item in compliance w/regulations at the time of inspection. "OUT" - Item out of compliance w/regulations at the time of inspection. "N/A" - Not Applicable - Means the section(s) of the regulation attributed a. Properly stored b. Properly labeled c. Properly used to that category of violation is not performed by the establishment. "N/O" - Not Observed - Means the section(s) of the regulation attributed to that category of violation was not being performed by the establishment at the time of the inspection. "FBI" - Foodborne illness risk factors are practices which are more likely to cause illness. ENVIRONMENTAL HEALTH SPECIALIST: RECEIVED BY: 08 POISONOUS OR TOXIC ITEMS TCHD S-79 Revised Apr-2013 www.tchd.org
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