Title Page
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ESTABLISHMENT NAME
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ESTABLISHMENT ADDRESS
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DOH PERMIT #
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OWNER NAME
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DATE
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TIME IN
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TIME OUT
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PURPOSE OF INSPECTION
FOODBORNE ILLNESS RISK FACTORS & PUBLIC HEALTH INTERVENTIONS
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Select designated compliance status (IN, OUT, N/O, N/A) for each numbered item:
IN=in compliance, OUT=not in compliance, N/O=not observed, N/A=not applicable
SUPERVISION
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1. Person in charge present, demonstrates knowledge, and performs duties
EMPLOYEE HEALTH
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2. Management awareness; policy present
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3. Proper use of reporting, restriction & exclusion
GOOD HYGIENIC PRACTICES
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4. Proper eating, tasting, drinking, or tobacco use
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5. No discharge from eyes, nose, and mouth
PREVENTING CONTAMINATION BY HANDS
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6. Hands clean and properly washed
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7. No bare hand contact with ready-to-eat foods or approved alternate method properly followed
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8. Adequate handwashing facilities supplied and accessible
APPROVED FOOD SOURCE
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9. Food obtained from approved source
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10. Food received at proper temperature
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11. Food in good condition, safe, and<br>unadulterated
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12. Required records available: shellstock tags, parasite destruction
PROTECTION FROM CONTAMINATION
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13. Food separated and protected
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14. Food contact surfaces: cleaned and sanitized
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15. Proper disposition of returned, previously served, reconditioned, and unsafe food
POTENTIALLY HAZARDOUS FOOD (TCS FOOD)
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16. Proper cooking time and temperatures
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17. Proper reheating procedures for hot holding
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18. Proper cooling time and temperatures
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19. Proper hot holding temperatures
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20. Proper cold holding temperatures
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21. Proper date marking and disposition
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22. Time as a public health control: procedures & records
CONSUMER ADVISORY
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23. Consumer advisory provided for raw or undercooked foods
HIGHLY SUCEPTIBLE POPULATIONS
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24. Pasteurized foods used; prohibited foods not offered
CHEMICAL
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25. Food additives: approved and properly used
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26. Toxic substances properly identified, stored, and used
CONFORMANCE WITH APPROVED PROCEDURES
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27. Compliance with variance, specialized process, parasite destruction and HACCP plan
GOOD RETAIL PRACTICES
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Good Retail Practices are preventative measures to control the introduction of pathogens, chemicals, and physical objects into foods.
Indicate "OUT" if numbered item is NOT in compliance.
SAFE FOOD AND WATER
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28. Pasteurized eggs used where required
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29. Water and ice from approved source
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30. Variance obtained for specialized processing methods
FOOD TEMPERATURE AND CONTROL
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31. Proper cooling methods used: adequate equipment for temperature control
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32. Plant food properly cooked for hot holding
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33. Approved thawing methods used
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34. Thermometers provided and accurate
FOOD IDENTIFICATION
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35. Food properly labeled; original container
PREVENTION OF FOOD CONTAMINATION
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36. Insects, rodents, and animals not present
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37. Contamination prevented during food preparation, storage, and display
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38. Personal cleanliness
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39. Wiping cloths: properly used and stored
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40. Washing fruits and vegetables
PROPER USE OF UTENSILS
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41. In-use utensils: properly stored
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42. Utensils, equipment and linens: properly stored, dried, handled
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43. Single-use/single-service articles: properly stored, used
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44. Gloves used properly
UTENSILS, EQUIPMENT AND VENDING
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45. Food and nonfood-contact surfaces cleanable, properly designed, constructed, and used
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46. Warewashing facilities: installed, maintained, used; test strips
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47. Nonfood-contact surfaces clean
PHYSICAL FACILITIES
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48. Hot and cold water available; adequate pressure
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49. Plumbing installed; proper backflow devices
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50. Sewage and waste water properly disposed
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51. Toilet facilities: properly constructed, supplied, clean
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52. Garbage/refuse properly disposed; facilities maintained
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53. Physical facilities installed, maintained, and clean
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54. Adequate ventilation and lighting; designated areas used
REPORT SUMMARY
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Sanitation Status/Score
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- GREEN: No more than one outstanding critical violation observed.
- YELLOW: At least one outstanding critical violation or a minimum of two critical violations observed.
- RED: At least one imminent health hazard/violation observed. Closure of the facility is recommended but not enforced by Pono Safety Solutions.
*The placard is property of Pono Safety Solutions. The placard shall remain on site at all times and shall not be removed, copied, or altered in any way. -
Remarks
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Food Temperature Observations
ACKNOWLEDGEMENT OF RECEIPT
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Follow-up Required
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Follow-up Date
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Signature of Person In Charge
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Signature of Agent/Inspector
