Mildura Rural City Council Food & Accommodation Assessment

• Premises name

• Reason for visit

  Select Complaint Mandatory Assessment Non-compliance New Premise Transfer Inspection Routine Assessment Food Safety Assessment Not required

  • Complaint
  • Mandatory Assessment
  • Non-compliance
  • New Premise
  • Transfer Inspection
  • Routine Assessment
  • Food Safety Assessment
  • Not required

• Document No.

• Trading name

• Type of premises

  Select Hotel Motel Hostel Student dormitory Holiday camp Labour hire accommodation Rooming house Residential accomodation

  • Hotel
  • Motel
  • Hostel
  • Student dormitory
  • Holiday camp
  • Labour hire accommodation
  • Rooming house
  • Residential accomodation

• Conducted on

  Date

• Prepared by

  Select Alana Nolen Brooke Keher Cathy Humphreys Malcolm Hare Cassie Vardandega Jeremy Draper Michelle Newman Bryce Kerr

  • Alana Nolen
  • Brooke Keher
  • Cathy Humphreys
  • Malcolm Hare
  • Cassie Vardandega
  • Jeremy Draper
  • Michelle Newman
  • Bryce Kerr
• Location
  Address

GENERAL INFORMATION

• Date and Time inspection began

  Date

• Registration name

• Address of premises

• Phone number

• Email address

• Name displayed on premises?

  Yes

  No

• Registration certificate available for inspection?

  Yes

  No

• Name of proprietor or staff in attendance

• Registration number

• Property File Number

• Number of staff

• Officer undertaking the assessment

  Select Alana Nolen Brooke Keher Cathy Humphreys Malcolm Hare Cassie Vardandega Jeremy Draper Michelle Newman Bryce Kerr

  • Alana Nolen
  • Brooke Keher
  • Cathy Humphreys
  • Malcolm Hare
  • Cassie Vardandega
  • Jeremy Draper
  • Michelle Newman
  • Bryce Kerr

ASSESSMENT TYPE

• Reason for the assessment

  Select Complaint Mandatory Assessment Non-compliance New Premise Transfer Inspection Routine Assessment Food Safety Assessment Not required

  • Complaint
  • Mandatory Assessment
  • Non-compliance
  • New Premise
  • Transfer Inspection
  • Routine Assessment
  • Food Safety Assessment
  • Not required

REINSPECTION DATE

• Is a re inspection required?

  Yes

  No

• Select date

  Date

• Is this food premises?

  Yes

  No

  N/A

• Food Safety Supervisor

FOOD SAFETY PROGRAM

• Class of Premises

  Class 1

  Class 2

  Class 3

  Class 3A

  Class 4

• Program Type

  Select Independant Registered Template v2 Class 3 Minimum Records Class 2 Community Group Class 3 Community Group No Food Safety Program on Site Registered Template v3

  • Independant
  • Registered Template v2
  • Class 3 Minimum Records
  • Class 2 Community Group
  • Class 3 Community Group
  • No Food Safety Program on Site
  • Registered Template v3

• Approved Suppliers list (1)

  Yes

  No

  N/A

• Goods Receival Form (2)

  Yes

  No

  N/A

• Storage Unit(s) temperature log (3)

  Yes

  No

  N/A

• Time log (4)

  Yes

  No

  N/A

• Equipment calibration log (5)

  Yes

  No

  N/A

• Activity Log (internal review process temperature log) (6)

  Yes

  No

  N/A

• Daily diary record sheet (7)

  Yes

  No

  N/A

• Cleaning schedule (8)

  Yes

  No

  N/A

• Approved suppliers list

  Yes

  No

  N/A

• Temperature checks of food in hot or cold storage

  Yes

  No

  N/A

• Cooking temperature checks

  Yes

  No

  N/A

• Use of 2 hour/4 hour rule for high risk food

  Yes

  No

  N/A

• Probe thermometer accuracy checks

  Yes

  No

  N/A

• Sushi preparation

  Yes

  No

  N/A

• Sushi display time log

  Yes

  No

  N/A

• Drying log

  Yes

  No

  N/A

• Meat display time log

  Yes

  No

  N/A

• Sous vide?

  Yes

  No

• Cooking method

  Yes

  No

  N/A

• Batch information?

  Yes

  No

  N/A

• Comments

• Copy of records

  Media

RECEIVING

• Protection from contamination (5(1) of 3.2.2)

  Yes

  No

  N/A

• Identification/traceability of food (5(2) of 3.2.2)

  Yes

  No

  N/A

• 
  Recommended Quality Assurance practice in relation to stock control regarding high risk product is to:
  a. ensure stock on purchase or receival has necessary labelling requirements, eg. use-by-date.
  b. only order stock quantity of product that is necessary, ie don’t overstock.
  c. keep product in its original packaging where possible.
  d. mark product with relevant details (eg discard date) when it undergoes a change of state or storage conditions (eg when thawed, cooked, opened, etc) and is to be subjected to further holding time. (3.2.2. (7.1a))
  
  

• Temperature control of PHF (5(3) and (4) of 3.2.2

  Yes

  No

  N/A

STORAGE

• Protection from contamination (6(1)(a) of 3.2.2)

  Yes

  No

  N/A

• Appropriate environmental conditions (6(1)(b) of 3.2.2

  Yes

  No

  N/A

• Temperature control of PHF (5(3) and (4) of 3.2.2)

  Yes

  No

  N/A

• Enter cooling storage type

Cooling storage type

• Location

• Coolroom

  Refrigerator

  Freezer

  Bain marie

• Select from range

• This is in the temperature Danger Zone why?

PROCESSING

• Safe and suitable food (7(1)(a) of 3.2.2)

  Yes

  No

  N/A

• Protection from contamination (7(1)(b)(i) of 3.2.2)

  Yes

  No

  N/A

• Adequate cooking/processing (7(1)(b)(ii) of 3.2.2)

  Yes

  No

  N/A

• PHF out of temp. control for min. time (7(2) of 3.2.2)

  Yes

  No

  N/A

• Cooling of PHF (7(3) of 3.2.2)

  Yes

  No

  N/A

• 7(3) A food business must,when cooling cooked potentially hazardous food, cool the food:
  (a) within two hours from 60 c to 21c; and
  (b) within a further four hours from 21c to 5c

• Reheating of PHF (7(4) of 3.2.2)

  Yes

  No

  N/A

• Are raw egg products produced?

  Yes

  No

  N/A

• What type of product is used?

  Select Raw egg Raw egg white Raw egg yolk Pasteurised raw egg acidified Other

  • Raw egg
  • Raw egg white
  • Raw egg yolk
  • Pasteurised raw egg
  • acidified
  • Other

• What types of food are produced?

  Select Mayonaise Aioli Hollandaise Egg butter Tiramisu Mouse Fried ice cream

  • Mayonaise
  • Aioli
  • Hollandaise
  • Egg butter
  • Tiramisu
  • Mouse
  • Fried ice cream

DISPLAY

• Protection from contamination (8(1), (2), (3) & (4) of 3.2.2)

  Yes

  No

  N/A

• Temperature control of PHF incl. frozen (8(5) of 3.2.2)

  Yes

  No

  N/A

• Enter heating unit type

Heating unit type

• Location

• Type of heated storage

  Select Bain marie hot box pie warmer holding cabinet portable food warmer hot food tables steamer rice warmer heat lamp

  • Bain marie
  • hot box
  • pie warmer
  • holding cabinet
  • portable food warmer
  • hot food tables
  • steamer
  • rice warmer
  • heat lamp

• Temperature

• This is the temperature danger zone why?

• Enter cooling storage type

Cooling storage type

• Location

• Type of cold display

  Select Bain Marie Sandwich bar Pizza ingredients Ice cream bar ice box Salad bar Deli display Frozen goods dairy cabinet drinks

  • Bain Marie
  • Sandwich bar
  • Pizza ingredients
  • Ice cream bar
  • ice box
  • Salad bar
  • Deli display
  • Frozen goods
  • dairy cabinet
  • drinks

• Select from range

• This in the temperature danger zone why?

PACKAGING

• Appropriate materials and process (9 of 3.2.2)

  Yes

  No

  N/A

• Food wraps and containers will not cause contamination?

  Yes

  No

  N/A

• Pre-packaged Foods (labelling) packed onsite?

  Yes

  No

  N/A
Type of food sold

• undefined

• Description of food FSC (1.2.2 1a)

  Yes

  No

  N/A

• Name and address of supplier FSC (1.2.2 2)

  Yes

  No

  N/A

• Lot identification FSC (1.2.2 2)

  Yes

  No

  N/A

• Mandatory & advisory warnings FSC (1.2.3)

  Yes

  No

  N/A

• Ingredients list in descending order (1.2.4)

  Yes

  No

  N/A

• Date marking FSC (1.2.5)

  Yes

  No

  N/A

• Storage conditions FSC (1.2.5)

  Yes

  No

  N/A

• Nutritional Information Panel (1.2.8)

  Yes

  No

  N/A

• Characterising ingredient FSC (1.2.10)

  Yes

  No

  N/A

TRANSPORTATION AND DISTRIBUTION

• Protection from contamination (10(a) of 3.2.2)

  Yes

  No

  N/A

• Temperature control PHF (10(b) & (c) of 3.2.2)

  Yes

  No

  N/A

RECALLS/FOOD DISPOSAL

• Food for disposal not sold/recall process (11, 12 of 3.2.2)

  Yes

  No

  N/A

• A food recall is action taken by a food business to remove unsafe food from distribution, sale and consumption. All food businesses must be able to quickly remove food from the marketplace to protect public health and safety. FSANZ coordinates and monitors food recalls in Australia.
  All consumer level recalls are listed on FSANZ current recalls web page. You can also stay informed by subscribing to the food recall alert - https://www.foodstandards.gov.au/media/pages/subscriptionservice.aspx

HEALTH, HYGIENE & KNOWLEDGE

• Health of food handlers - responsibilities (14 of 3.2.2)

  Yes

  No

  N/A

• Any food handler with symptoms or a diagnosis of an illness (such as vomiting, diarrhoea or fever) must:
  • report that they are ill to their employer or supervisor
  • not handle food if there is a reasonable likelihood of food contamination as a result of the illness
  • if continuing to engage in other work on the food premises, take all practicable measures to prevent food from being contaminated
  • notify a supervisor if they know or suspect they may have contaminated food

• Hygiene of food handlers - responsibilities (13, 15 of 3.2.2)

  Yes

  No

  N/A

• Measures the food handler can take, if the food handler is responsible for these tasks, to
  minimise the likelihood of compromising food safety and suitability include (to the extent
  that is reasonable):
  • ensuring food is cooked or processed correctly;
  • ensuring potentially hazardous food is being maintained at the correct temperature or,
  if time is being used as a control, that the maximum amount of time has not been
  exceeded;
  • ensuring food is adequately protected from contamination;
  • ensuring eating and drinking utensils and food contact services are correctly cleaned
  and sanitised;
  • ensuring food contact surfaces are adequately protected from contamination; and
  • reporting to a supervisor if equipment is not working correctly.
  

• Food business - responsibilities (16, 18 of 3.2.2)

  Yes

  No

  N/A

• Adequate hand washing facilities (17 of 3.2.2)

  Yes

  No

  N/A

• Food handling - skills & knowledge (3 of 3.2.2)

  Yes

  No

  N/A

• Are staff aware of food allergy hazards?

  Yes

  No

  N/A

• The Australian New Zealand Food Standards Code states food businesses must advise customers of eight allergens in food, either on the package of a food or on request by the customer. These are: 1. Cereals and products containing gluten - wheat, rye, barley, oats, spelt, and kamut, and their hybrid strains, 2. Crustaceans such as crabs, lobster, shellfish, and their products, 3. Egg and egg products, 4. Fish and fish products, 5. Milk and milk products, 6. Nuts, such as tree nuts, almonds, hazelnuts, walnuts, cashews, peanuts, pecan nuts, brazil nuts, pistachio nuts, macadamia nuts, sesame nuts, and their products, 7. Soybeans and their products, 8. Added sulphites levels of 10mg/kg or more.
  

PREMISES AND HYGIENE

• Cleanliness of premises, fittings, equipment (19 of 3.2.2)

  Yes

  No

  N/A

• Are tables and chairs including high chairs cleaned between customers use?

  Yes

  No

  N/A

• Cleaning/sanitising of food contact surfaces (20 of. 3.2.2)

  Yes

  No

  N/A

• Are separate utensils and equipment used for ready to eat foods sanitised unless disinfected in a dishwasher?

  Yes

  No

  N/A

• Suitability and maintenance of premises, fittings and equipment (21 of 3.2.2 and 3, 10, 11 & 12 of 3.2.2)

  Yes

  No

  N/A

• undefined

• undefined

• Temperature measuring device (22 of 3.2.2)

  Yes

  No

  N/A

• Use of "single use" items (23 of 3.2.2)

  Yes

  No

  N/A

• Control of animals and pests (24 of 3.2.2)

  Yes

  No

  N/A

• Water supply adequate and potable (4 of 3.2.3)

  Yes

  No

  N/A

• Disposal of sewage and waste water (5 of 3.2.3)

  Yes

  No

  N/A

• Storage of refuse & recyclable matter (6 of 3.2.3)

  Yes

  No

  N/A

• Is waste food being collected by persons for animal feed?

  Yes

  No

• Adequate ventilation and lighting (7 & 8 of 3.2.3)

  Yes

  No

  N/A

• 
  
  Lighting
  Lighting to comply with Australian Standard 1680.
  Storage area Lux reading is to be a minimum of 110-150.
  Food preparation area lux reading is to be a minimum of 500.
  Lighting for reading inspection and monitoring equipment areas lux reading is to be a minimum of 600-1200.
  
  
  
  
  Ventilation
  Canopy effluent discharge is to be in conformity with Australian Standard 1668.2
  (a) The exhaust airflow rate for kitchen exhaust canopies shall be at least 0.38m3 / second / m2 of the top surface area of the cooking equipment to be ventilated.
  (b) Exhaust velocity at the point of discharge shall be at least 5m/second.
  (c) Make up air shall be supplied to the kitchen or cooking area by either permanent natural ventilation or an approved mechanical ventilating supply system capable of supplying not less than 10 complete air changes per hour, where the make up air is free from contamination and impurity.
  
  The filters shall be removed and thoroughly cleaned on a regular basis to ensure they are kept in a clean condition at all times. The internal surfaces of the exhaust ductwork shall be cleaned on at least a six monthly basis. The mechanical exhaust system shall operate at all times when cooking or heating is carried out.

• Storage of personal effects/chemicals (15 of 3.2.3)

  Yes

  No

  N/A

• Adequate toilet facilities (16 of 3.2.3)

  Yes

  No

  N/A

ACCOMMODATION

• Does this premises have accommodation?

  Yes

  No

  N/A
Tap to enter information

• What type of accommodation?

  Select Motel Hotel Boarding house Back Packers Bed and Breakfast Rooming house Holiday camp Student dormitories Hostel

  • Motel
  • Hotel
  • Boarding house
  • Back Packers
  • Bed and Breakfast
  • Rooming house
  • Holiday camp
  • Student dormitories
  • Hostel

• Do bedrooms need to be measured?

  Yes

  No

  N/A
Bedroom

• Size of bedroom (sqm.):

• Max no. Persons permitted:

  Select Room not for rent No access to bedroom < 7.5 sqm 0 insufficient size 7.5 to 10 sqm 1person for more than 31 days 2 persons for 31 days or less 10 to 12sqm 1 persons for more than 31 days, 3 persons for 31 days or less 12 to 14 sqm 2 persons for stays more than 31 days, 4 persons for stays 31 days or less 14 to 16 sqm 2 persons for stays more than 31 days, 5 persons for stays 31days or less 16 to 18 sqm 3 persons for stays 31 days or more, 6 persons for stays 31 days or less 18 to 20 sqm 3 persons for stays more than 31 days, 7 persons for stays 31 days or less 20 to 22 sqm 4 persons for stays more than 31 days, 8 persons for stays 31 days or less 22 to 24 sqm 4 persons for stays more than 31 days, 9 persons for stays 31 days or less 24 to 26 sqm 5 persons for stays more than 31 days, 10 persons for stays 31 days or less 26 to 28 sqm 5 persons for stays more than 31 days, 11 persons for stays 31 days or less 28 to 30 sqm 6 persons for stays more than 31 days, 12 persons for stays 31 days or less 30 to 32 sqm 6 persons for stays more than 31 days, 12 persons for stays 31 days or less 32 to 34 sqm 7 persons for stays more than 31 days,15persons for stays 31 days or less 34 to 36 sqm 7 persons for stays more than 31 days, 16 persons for stays 31 days or less 36 to 38 sqm 8 persons for stays more than 31 days, 16 persons for stays 31 days or less 38 to 40 sqm 8 persons for stays more than 31 days, 17 persons for stays 31 days or more > 40 sqm do calculations

  • Room not for rent
  • No access to bedroom
  • < 7.5 sqm 0 insufficient size
  • 7.5 to 10 sqm 1person for more than 31 days 2 persons for 31 days or less
  • 10 to 12sqm 1 persons for more than 31 days, 3 persons for 31 days or less
  • 12 to 14 sqm 2 persons for stays more than 31 days, 4 persons for stays 31 days or less
  • 14 to 16 sqm 2 persons for stays more than 31 days, 5 persons for stays 31days or less
  • 16 to 18 sqm 3 persons for stays 31 days or more, 6 persons for stays 31 days or less
  • 18 to 20 sqm 3 persons for stays more than 31 days, 7 persons for stays 31 days or less
  • 20 to 22 sqm 4 persons for stays more than 31 days, 8 persons for stays 31 days or less
  • 22 to 24 sqm 4 persons for stays more than 31 days, 9 persons for stays 31 days or less
  • 24 to 26 sqm 5 persons for stays more than 31 days, 10 persons for stays 31 days or less
  • 26 to 28 sqm 5 persons for stays more than 31 days, 11 persons for stays 31 days or less
  • 28 to 30 sqm 6 persons for stays more than 31 days, 12 persons for stays 31 days or less
  • 30 to 32 sqm 6 persons for stays more than 31 days, 12 persons for stays 31 days or less
  • 32 to 34 sqm 7 persons for stays more than 31 days,15persons for stays 31 days or less
  • 34 to 36 sqm 7 persons for stays more than 31 days, 16 persons for stays 31 days or less
  • 36 to 38 sqm 8 persons for stays more than 31 days, 16 persons for stays 31 days or less
  • 38 to 40 sqm 8 persons for stays more than 31 days, 17 persons for stays 31 days or more
  • > 40 sqm do calculations

• No. of beds:

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 other

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • other

• No. of persons currently residing in this room:

  Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 other

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • other

• Add media

  Media

• Do no. of occupants comply re crowding?

  Yes

  No

  N/A

• Room number on each room or dorm?

  Yes

  No

  N/A

• The minimum floor area of a room or cubicle is 7.5m2
  Persons stay for long term (greater than 31days) 12m2= 1 person + 4m2 for each additional person
  Persons stay (less than 31days) 7.5m2 -10m2 = 2 persons > 10m2 = 3 persons + 2m2 for each additional person
  Holiday camp must provide 2m2 for each person staying < 31days
  NB: 1 child < 3 years old is not counted as a person. 2 children < 3 years old counted as one person.
  Floor area includes any built in cupboard and furniture.

• Is a register kept and up to date?

  Yes

  No

  N/A

• R26 Record of names, addresses of persons occupying ,dates of arrival and departure.
  Records to be kept for 12 months after the date of last entry.

GENERAL AREA

• Water supply

  Select Reticulated town supply Non potable Bottle water

  • Reticulated town supply
  • Non potable
  • Bottle water

• R 20 Water supplied to:<br>Bathing (hot & cold)<br>Kitchen (hot & cold)<br>Laundry (hot & cold)<br>R 21 Drinking water (must be potable)

  Yes

  No

  N/A

EMERGENCY

• Access and egress paths clear?

  Yes

  No

  N/A

• Fire fighting equipment easily accessible ?

  Yes

  No

  N/A

• Fire fighting equipment checked in last 6 months?

  Yes

  No

  N/A

• Adequate lighting and exit signage?

  Yes

  No

  N/A

• Dose the premises contain or require interlinked smoke detectors?

  Not required

  Installed

  Not installed

  Battery operated installed

  Not operating

• If not interlinked refer to building surveyor?

  Yes

  No

  N/A

COMMON AREAS

• Clean and tidy?

  Yes

  No

  N/A

• Refrigerators and storage cupboards clean out regularly?

  Yes

  No

  N/A

• BBQ cleaned if supplied?

  Yes

  No

  N/A

• Cups, glassware and crockery sanitised correctly?

  Yes

  No

  N/A

BATHROOMS

• Is a bathroom assessment required?

  Yes

  No

  N/A
Bathroom

• Amenities

  Select 1 Toilet 1 Shower 1 Bath 1 Basin 2 Toilets 2 Showers 2 Baths 2 Basins Other

  • 1 Toilet
  • 1 Shower
  • 1 Bath
  • 1 Basin
  • 2 Toilets
  • 2 Showers
  • 2 Baths
  • 2 Basins
  • Other

• Add media

  Media

• Do no. Of amenities comply with PH&WB requirements?<br>Note 1 toilet,1 bath/shower & 1hand basin required for every 10 persons or part thereof.

  Yes

  No

  N/A

• Clean and tidy?

  Yes

  No

  N/A

LAUNDRY FACILITIES

• What facilities are provided?

• undefined

  Select Washing machine Trough Dryer

  • Washing machine
  • Trough
  • Dryer

• Is linen cleaned commercially?

  Yes

  No

  N/A

• Is linen changed at least weekly or on change of occupant?

  Yes

  No

  N/A

WASTE DISPOSAL

• Sufficient vermin proof receptacles provided.

  Yes

  No

  N/A

• All emptied and cleaned regularly?

  Yes

  No

  N/A

MAINTENANCE

• Room photos

  Media

• Floors and walls?

  Yes

  No

  N/A

• Ceilings?

  Yes

  No

  N/A

• Furniture and beds?

  Yes

  No

  N/A

• Pest control including bed bugs and fleas?

  Yes

  No

  N/A

SWIMMING POOLS AND SPAS

• Has this premise have a Pool?

  Yes

  No

  N/A

• Type of test kit

  photometer

  colorimetric

  standard comparator

• Have records of the following parameters been maintained at the frequency specified?

  Yes

  No

  N/A

• Log books to be kept for at least 12 months after the last entry and available on demand to an authorised officer. The records should then be archived for a further six years.

• Free chlorine recorded daily

  Yes

  No

  N/A

• Total chlorine recorded daily

  Yes

  No

  N/A

• Free bromine recorded daily

  Yes

  No

  N/A

• Combined chlorine recorded daily

  Yes

  No

  N/A

• pH recorded daily

  Yes

  No

  N/A

• Alkalinity recorded weekly

  Yes

  No

  N/A

• Cyanuric acid recorded weekly

  Yes

  No

  N/A

• Chlorinated Pools
  
  Chlorine Residual Spa Pools Swimming Pools
  Cyanuric Acid Cyanuric Acid Cyanuric Acid Cyanuric Acid
  Not Present Present Not present Present
  Free Chlorine Minimum 2 mg/L 3 mg/L 1 mg/L 2 mg/L
  Free Chlorine Maximum 8 mg/L 8 mg/L 8 mg/L 8 mg/L
  

• Brominated Pools
  
  Bromine Residual Spa Pools Swimming Pools
  Free Bromine Minimum 4 mg/L or 2 mg/L measured 2 mg/L or 1 mg/L measured
  as a chlorine equivalent as a chlorine equivalent
  Total Bromine Maximum. 8 mg/L or 4 mg/L measured 8 mg/L or 4 mg/L measured
  as a chlorine equivalent as a chlorine equivalent.

• Other tests
  Minimum Maximum
  pH 7.2. 8.0
  Total Alkalinity 60 mg/L -
  Cyanuric Acid - 100 mg/L
  Temperature of 40°C
  Operation

Chlorine Pool

• Add media

  Media

• Pool type

  Select spa swim spa 50 metre 25 metre diving pool toddler wave slide leisure

  • spa
  • swim spa
  • 50 metre
  • 25 metre
  • diving pool
  • toddler
  • wave
  • slide
  • leisure

• Construction

  Concrete

  Fibreglass

  vinyl liner

• Disinfection system

  Salt Chlorinator (auto)

  Metered Liquid

  Gas (automatic)

• Bathing load at time of assessment ?

  light

  medium

  heavy

• Is the pool clean and free of debris?

  Yes

  No

  N/A

• Test required?

  Yes

  No

  N/A

• Free chlorine

• Combined chlorine

• pH range

• Alkalinity

• Cyanurate

• Comments or action required

Chlorine Spa

• Add media

  Media

• Pool type

  Select spa swim spa 50 metre 25 metre diving pool toddler wave slide leisure

  • spa
  • swim spa
  • 50 metre
  • 25 metre
  • diving pool
  • toddler
  • wave
  • slide
  • leisure

• Construction

  Concrete

  Fibreglass

  vinyl liner

• Disinfection system

  Salt Chlorinator (auto)

  Metered Liquid

  Gas (automatic)

• Bathing load at time of assessment ?

  light

  medium

  heavy

• Is the pool clean and free of debris?

  Yes

  No

  N/A

• Test required?

  Yes

  No

  N/A

• Free chlorine

• Total chlorine

• Combined chlorine

• pH range

• Alkalinity

• Cyanurate

• Comments or actions required

Bromine Pool

• Add media

  Media

• Pool type

  Select spa swim spa 50 metre 25 metre diving pool toddler wave slide leisure

  • spa
  • swim spa
  • 50 metre
  • 25 metre
  • diving pool
  • toddler
  • wave
  • slide
  • leisure

• Construction

  Concrete

  Fibreglass

  vinyl liner

• Disinfection system

  Salt Chlorinator (auto)

  Metered Liquid

  Gas (automatic)

• Bathing load at time of assessment ?

  light

  medium

  heavy

• Is the pool clean and free of debris?

  Yes

  No

  N/A

• Test required?

  Yes

  No

  N/A

• Total bromine

• pH range

• Alkalinity

• Cyanurate

• Comments or action required

Bromine Spa

• Add media

  Media

• Pool type

  Select spa swim spa 50 metre 25 metre diving pool toddler wave slide leisure

  • spa
  • swim spa
  • 50 metre
  • 25 metre
  • diving pool
  • toddler
  • wave
  • slide
  • leisure

• Construction

  Concrete

  Fibreglass

  vinyl liner

• Disinfection system

  Salt Chlorinator (auto)

  Metered Liquid

  Gas (automatic)

• Bathing load at time of assessment ?

  light

  medium

  heavy

• Is the pool clean and free of debris?

  Yes

  No

  N/A

• Total bromine

• pH range

• Alkalinity

• Cyanurate

• Comments or actions required

TOBACCO

• Tobacco laws apply?

  Yes

  No

  N/A

• undefined

  Select Smoke free dining Tobacco retailer Outdoor drinking or dining Smoke free dining and tobacco retailer Vending machine Smoke free dining and vending machine

  • Smoke free dining
  • Tobacco retailer
  • Outdoor drinking or dining
  • Smoke free dining and tobacco retailer
  • Vending machine
  • Smoke free dining and vending machine

• Is smoke free signage displayed in dining areas?

  Yes

  No

• Is there an outdoor dining area?

  Yes

  No

• Signage?

  Yes

  No

• Barriers or buffer zone correct?

  Yes

  No

• Is there an outdoor drinking area?

  Yes

  No

• Correct buffer zones or separation in place?

  Yes

  No

• Is there a vending machine?

  Yes

  No

• General retailer

  Yes

  No

  N/A

• Is the vending machine located in a correct position (in the line of sight of the bar area not more than 5<br>metres from the outer edge of the bar area in a licensed premises, or in the line of sight of counter at a<br>gaming venue or casino, or next to the counter at a bottle shop)?

  Yes

  No

  N/A

• Are tobacco products and packaging covered and not visible inside or outside of the vending machine?<br>(price tickets permitted)

  Yes

  No

  N/A

• Are tobacco products and packaging (cigarettes, cigars, loose tobacco and cigars inside humidors) covered and not visible to the public from anywhere inside or outside the retail premises?

  Yes

  No

  N/A

• Is the health warning sign displayed?

  Yes

  No

  N/A

• Is the ‘We don’t sell tobacco to u/18s sign’ displayed?

  Yes

  No

  N/A

• Are staff being trained regarding cigarette sales to minors?

  Yes

  No

  N/A

• Are there any 'discounted' or 'cheap' cigarette signs?

  Yes

  No

• Not selling single cigarettes or in packs less than 20?

  Yes

  No

• Any signs that smoking may be occurring in the workplace (eg butts, smell )?

  Yes

  No

• Has the tobacco sales area have a price board?

  Yes

  No

  N/A

• Is a graphic warning sign displayed on or near the price board?

  Yes

  No

  N/A

• Workplace smoking The entire enclosed workplace to be smoke-free at all times. Smoking status of a workplace never changes even if doors and windows are opened. Smoking status of an outdoor area can change if awning (or similar) are drawn. Occupier must not provide ash trays, matches, lighters or any other things designed to facilitate smoking. If an occupier witnesses smoking in their workplace they should request that the person extinguish the cigarette. Where possible, designate an outside area as the area where smoking is permitted. A cigarette butt bin should be provided in designated outdoor smoking areas Educating new staff regarding the smoke-free enclosed workplace.

COMMENTS/ACTIONS TO BE TAKEN

• Reinspect

  Nil

  Letter

  Infringement

  Order

REINSPECTION DATE

• Is a re inspection required?

  Yes

  No

• Select date

  Date

SIGNATURES

• Signature of Proprietor/Staff

  Sign

• Signature of Officer

  Sign