Global Food Safety Self Assessment Form

• Date and Time

  Date

• Evaluator

• Store Manager

• Manager In Charge

• Franchisee

• Location
  Address

• Store Number

• Store Name

Food Safety Risk Factors

• All products dated as per Domino's shelf life guide and product standards and not expired

  Yes

  No

  N/A

• Calibrated thermometers in use

  Yes

  No

  N/A

• All cooked product temperatures 165°F / 74t or above

  Yes

  No

  N/A

• All refrigerated product must be held at 41°F / 5t or lower

  Yes

  No

  N/A

• Frozen products are thawed under refrigeration

  Yes

  No

  N/A

• All food products are fully protected from cross-contamination and covered in prep, dry and cold storage

  Yes

  No

  N/A

• Pest control services completed, report available for review and no unapproved pesticides present

  Yes

  No

  N/A

• No evidence of pests

  Yes

  No

  N/A

• Store personnel following hair and hygiene practices

  Yes

  No

  N/A

• All hand sinks properly stocked

  Yes

  No

  N/A

• Hand washing and sanitizing

  Yes

  No

  N/A

• Delivery bags clean and well maintained

  Yes

  No

  N/A

• All food-contact surfaces clean and sanitized

  Yes

  No

  N/A

• All food-contact surfaces in good repair

  Yes

  No

  N/A

• Sanitizer in-use and at proper concentration or temperature as applicable, including warewashing and sanitizer buckets/bottles

  Yes

  No

  N/A

• Current Food safety certification available as required

  Yes

  No

  N/A

• Products purchased from approved suppliers

  Yes

  No

  N/A

• Eating and drinking in back of house

  Yes

  No

  N/A

Cleanliness

• Makeline clean

  Yes

  No

  N/A

• Walk-in cooler clean

  Yes

  No

  N/A

• Other refrigeration and beverage units clean

  Yes

  No

  N/A

• Freezer units clean

  Yes

  No

  N/A

• Refrigeration gaskets maintained clean

  Yes

  No

  N/A

• Oven and oven hood clean

  Yes

  No

  N/A

• Hot rack and hot holding cabinets clean

  Yes

  No

  N/A

• Hand wash sinks clean and used only For hand washing

  Yes

  No

  N/A

• Dishwashing area clean

  Yes

  No

  N/A

• All interior trash cans and dumpster area are clean

  Yes

  No

  N/A

• Floors and drains are clean

  Yes

  No

  N/A

• Baseboards clean

  Yes

  No

  N/A

• Walls clean

  Yes

  No

  N/A

• Ceiling tiles, lights and light covers clean

  Yes

  No

  N/A

• Storage equipment clean

  Yes

  No

  N/A

• Other non-food contact surfaces clean

  Yes

  No

  N/A

• Dough equipment clean

  Yes

  No

  N/A

• Front counter clean

  Yes

  No

  N/A

• Restrooms clean and sanitary

  Yes

  No

  N/A

Maintenance and Facility

• Makeline in good repair

  Yes

  No

  N/A

• Walk-in cooler in good repair

  Yes

  No

  N/A

• Other refrigeration and beverage units in good repair

  Yes

  No

  N/A

• Freezer units in good repair

  Yes

  No

  N/A

• Refrigeration gaskets in good repair

  Yes

  No

  N/A

• Oven and oven hood in good repair

  Yes

  No

  N/A

• Hot holding equipment in good repair

  Yes

  No

  N/A

• Hand wash sink in good repair

  Yes

  No

  N/A

• Dishwashing area and equipment in good repair

  Yes

  No

  N/A

• All interior and exterior trash cans (including dumpster area) in geed repair and pest proof

  Yes

  No

  N/A

• Floors and drains in good repair

  Yes

  No

  N/A

• Baseboards in good repair

  Yes

  No

  N/A

• Walls in good repair

  Yes

  No

  N/A

• Ceiling tiles, lights and light covers in good repair

  Yes

  No

  N/A

• Storage equipment in good repair

  Yes

  No

  N/A

• Other non-food contact surfaces in good repair

  Yes

  No

  N/A

• Dough equipment in good repair

  Yes

  No

  N/A

• Front counter in good repair

  Yes

  No

  N/A

• Restroom and fixtures in good repair

  Yes

  No

  N/A

• No temporary repairs

  Yes

  No

  N/A

• Backflow devices and air breaks/gaps present

  Yes

  No

  N/A

Storage

• AU prepped food products stored in separate containers

  Yes

  No

  N/A

• Food must be fully thawed prior to use

  Yes

  No

  N/A

• All Food, equipment, packaging and Food contact items are stored off the floor and protected from contamination

  Yes

  No

  N/A

• Working thermometers in walk-in cooler, makehne, beverage cooler, or other refrigeration units

  Yes

  No

  N/A

• Chemicals properly labelled; correct use of sanitizer and detergent

  Yes

  No

  N/A

• Wiping cloths are properly stored and appropriate test strips are available

  Yes

  No

  N/A

• Proper storage of personal food and personal items

  Yes

  No

  N/A

• Frozen products are solid to the touch

  Yes

  No

  N/A

• Allergens stored separated to prevent cross contamination

  Yes

  No

  N/A

Knowledge and Compliance

• Knowledge of health of food handlers and personal hygiene

  Yes

  No

  N/A

• Regulatory or Local Health inspections: knowledge of procedure

  Yes

  No

  N/A

• Knowledge of employee health policy

  Yes

  No

  N/A

• Food license registration or business registrations available

  Yes

  No

  N/A

• Temperature logs are available and complete with corrective actions

  Yes

  No

  N/A

• Disease Control and Emetic Event kit and Plan

  Yes

  No

  N/A

• Ceramic, glass or glass breakage procedure in place

  Yes

  No

  N/A

• Sanitation schedule and plan in place

  Yes

  No

  N/A

• SDS available for all chemicals in the store

  Yes

  No

  N/A

• Cleaning tools and equipment are in good repair and maintained clean

  Yes

  No

  N/A

• Food safety standards available

  Yes

  No

  N/A

Extreme Violations

• All practicable measures to eradicate and prevent the harbourage of pests

  Yes

  No

  N/A

• Maintain the food premises, fixtures, fittings and equipment to the required standard of operating

  Yes

  No

  N/A

• Ensure the public is adequately protected; such as ceasing operating during FBI outbreak, ill employees working, working without potable or drinkable water, a boil water advisory is in place, no electricity or sew age backup

  Yes

  No

  N/A

• Maintain the integrity of product quality and ensure safety

  Yes

  No

  N/A

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• Name and Signature

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