Title Page

  • Conducted on

  • Prepared by

  • Address
  • Store Number:

  • Manager on Duty:

Fountain

  • All items including allergens labeled, separated with no cross contamination.

  • Scoops and spades clean and in good condition.

  • All food items not in use covered; anything out of original container stored in microlites are labeled<br>

  • Proper use of day dots<br>

  • PHF foods in refridgeration stored at £ 41° <br>

  • Items stored in fountain rail £ 45° <br>

  • Ice cream temperature £ 12°, and FriendZ mix temperature £ 15°<br>

  • Thermometers present, working, and easily visible in all cold holding units; not cross contaminating food, and removed from original packaging<br>

  • Food contact surfaces of fountain equiptment properly cleaned<br>

  • Non food contact surfaces in fountain properly cleaned and in good repair<br>

  • Dipper well running with plug in place when ice cream scoops are present in well<br>

  • Gasket & lids clean and in good repair<br>

  • Flatware/ paper goods stores properly<br>

Kitchen, Food Prep and Storage

  • Potentially hazardous foods, including shell eggs, in refrigerated drawers or line refrigerators ≤41°F<br>

  • Breakfast items ≤41°F or time stamped and held for less than 4 hours<br>

  • Potentially hazardous foods in walk in refrigerator ≤41°F<br>

  • Potentially hazardous foods in walk in freezer ≤ 0°F and in stand up freezer ≤ 10°F<br>

  • Dressings and condiments in Squeeze bottles ≤45°F<br>

  • Thermometers present, working, and easily visible in all cold holding units; not cross contaminating food, and removed from original packaging<br>

  • All gaskets in kitchen, including in the walk in cooler & freezer, are clean and not torn<br>

  • Microwave surfaces throughout restaurant clean and maintained<br>

  • No cross contamination of crocks in salad unit; crocks not filled less than 1" from top; and, interior of salad unit clean and maintained<br>

  • Walk in cooler clean<br>

  • Walk in cooler in good repair<br>

  • Walk in freezer clean and floors free of excessive ice build-up<br>

  • Walk in freezer in good repair<br>

  • Steam table products ≥140°F (160° - 175° FIC standard)<br>

  • Soup & Chowder ≥140°F (160° - 180° FIC standard)<br>

  • Minimum cooking temperatures met<br>

  • Proper thawing of foods<br>

  • All food items covered<br>

  • Raw food including shell eggs stored properly<br>

  • Allergens in kitchen properly stored<br>

  • Proper use of day dot system<br>

  • Potentially hazardous food products not expired<br>

  • Utensils clean and stored properly<br>

  • Cutting boards clean and in good condition<br>

  • Knives clean, in good condition and stored properly<br>

  • Food prep & storage containers clean, not cracked, NSF approved and stored properly<br>

  • Slicer and dicer and lettuce spinner clean<br>

  • Grill hoods professionally cleaned and Ansul within last 6 months. K Type & ABC Fire extinguishers present, mounted, dated and not expired. Extinguishers charged<br>

  • Grill screens present, clean, and in good condition, no gaps or missing screens<br>

  • All equipment commercial grade<br>

  • Dry storage area clean<br>

  • Dry storage area in good repair<br>

  • Food, including allergens, protected during storage and free from contamination<br>

  • No reuse of single service items<br>

  • China/Glassware clean and stored properly<br>

  • Squeeze bottles clean<br>

  • Grill surface, exterior of grill, grill stand, grill board, wheels/legs are clean - no build up<br>

  • BONUS QUESTION: Deep fat fryers are clean inside and out, including inside cabinet under unit<br>

  • All other kitchen equipment clean – stand up freezer, grill drawer, heat lamps, toasters, soup wells, French fry holding cabinet, shelving, holding units, Panini press, broiler, Ovention ovens<br>

  • Dish washer reaching proper temperature/PPM<br>

  • Dish washer is not leaking, gauge is accurate and rinse pressure is appropriate<br>

  • Dish washer is clean<br>

  • 3 Bay Sink labeled and MOD knows procedure for use<br>

  • Broken glass bucket present<br>

  • Ice scoop/ice bucket stored properly and in good condition<br>

  • Ice machine interior clean<br>

  • Ice machine exterior clean<br>

  • Mops, brooms & buckets clean and stored properly<br>

  • Cleaning supplies properly stored<br>

  • Ecolab chemicals properly titrated<br>

  • Cleaning supplies properly labeled and MSDS/SDS present<br>

  • 2 Emetic kits present, stocked and properly stored<br>

Service Aisle

  • Potentially hazardous food in service aisle salad unit or upright refrigerator ≤41˚F<br>

  • Potentially hazardous food in condiment/expo rail ≤45°F<br>

  • Dressings stored ≤45°F in clean containers, no cross contamination<br>

  • All food items not in use covered<br>

  • Salad unit or upright refrigerator clean<br>

  • Salad unit or upright refrigerator gaskets are clean and not torn<br>

  • Allergens labeled, covered, separated and stored properly<br>

  • Utensils clean and correctly stored<br>

  • Thermometers present, working, and easily visible in all cold holding units; not cross contaminating food, and removed from original packaging<br>

  • Food contact surfaces (shelving and serving trays) clean and maintained<br>

  • Soda machine clean and maintained and ice scoop present properly stored<br>

  • Coffee & tea machine surfaces clean & maintained<br>

  • Silverware/ paper goods stored properly<br>

General Facilities- Floors/walls/ceilings and Backflow Prevention

  • Walls, ceilings, light fixtures and vents clean<br>

  • Lighting provided as required and shielded/shatter proof. Light shields present are in good repair and no light bulbs burnt out in food prep and storage areas.<br>

  • Floors and baseboards clean, drain covers present; choose the appropriate answer depending on the number of areas observed with unclean floors<br>

  • Floor drains clean<br>

  • Floors and baseboards in good condition<br>

  • No cross-connection, back siphon age, backflow<br>

  • All trash cans are clean; select the correct answer based on the number of occurrences observed<br>

  • Walls, ceilings and vents in good condition<br>

Dining Room

  • Greeter stand/area clean and organized<br>

  • Menus and menu inserts clean and not torn<br>

  • Retail Cabinet clean, stocked properly<br>

  • Ceilings, vents, walls, woodwork clean and in good condition<br>

  • Windows and window treatments clean and maintained<br>

  • Floors/ Carpet/ Baseboards clean and in good condition<br>

  • Booths and tables cushions, edges, bases, legs, chairs clean & in good condition<br>

  • High chairs/boosters clean and in good condition<br>

  • Items on tables clean<br>

  • Dining room cleaning tools clean, maintained and stored properly<br>

  • Dining room lights clean and functioning<br>

  • Comfortable ambiance<br>

Rest Rooms

  • Ceilings and fixtures clean and in good condition<br>

  • Restrooms are odor free<br>

  • Restroom supplies stocked<br>

  • Toilet rooms enclosed, self-closing/locking doors<br>

  • Floors and baseboards clean, drain covers present<br>

  • Floor drains clean<br>

  • Floors and baseboards in good condition<br>

  • Walls clean, in good condition<br>

Overall Food Safety Behaviors and Documentation

  • Hand washing sinks stocked, in good repair with nothing blocking access<br>

  • Proper glove use and hand washing observed<br>

  • Thermometer present and calibrated, back up thermometer present<br>

  • Employee food properly stored, no eating or drinking in food prep areas<br>

  • Anti-choking procedures posted<br>

  • Management Personnel (anyone who runs a shift) has food safety certificate present<br>

  • Food handler food safety knowledge questions<br>

  • Exclusion / restriction policies posted or manager knowledgeable of exclusion/restriction policies<br>

  • HACCP forms and daily walk thrus complete<br>

  • All criticals on most recent health department inspection are corrected<br>

  • Produce washed prior to prep and no other cross contamination present<br>

  • Appropriate test strips present<br>

  • Sanitizer solution stored in red bucket, at proper concentration, in proper location and wiping cloths stored in buckets<br>

  • The 30 Minute Shake is occurring<br>

Employee Appearance

  • Employees wearing proper hair restraints<br>

  • Personal belongings stored separately, away from food, food prep areas and paper products<br>

  • Employees have finger nails clean and neatly trimmed, no fake nails or colored nail polish; and, are following the jewelry policy<br>

Adherence to Employment Break Regulations

  • Employee break policies are being followed<br>

Insect, Rodent, Animal Control

  • Pest activity not present<br>

  • Pest prevention properly in place<br>

  • Fly lights properly installed<br>

Exterior

  • Dumpster area clean, in good condition with no signs of rodent activity<br>

  • Grease dumpster clean with no spillage and lid closed<br>

  • Parking lot and sidewalks clean<br>

  • Parking lot and sidewalks in good condition<br>

  • Shrub beds clean<br>

  • Trash cans/ashtrays empty and clean<br>

  • Vestibule/Carryout clean, free of clutter and no odor<br>

  • Back door exterior, surrounding area and pad clean<br>

  • Exterior lighting working and clean; exterior signage present and clean<br>

  • Carryout area in good condition and lights working<br>

Employee Safety

  • Slip Resistant Shoes

  • Company Locations Only: Slip resistant overshoes available and procedure in place for issuing to employees<br>

  • Cut proof gloves for food prep<br>

  • PPE present and readily available<br>

  • Bandages available<br>

  • Wet Floor signs on hand<br>

  • Back door area clean, security policy sticker posted, door alarmed, and if rear door is unlocked/open MOD is present<br>

  • Company Locations Only: 22 Gallon trash can in use<br>

  • Auditor Signature

  • MOD Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.