inspection report form

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