Information

  • QASA

  • Store

  • Conducted on

  • Prepared by

  • Personnel

Behaviors

Self Assessment

Chemicals

  • Chemicals are not stored on or above food preparation counters.

  • Chemicals are stored below or 12 inches away from food/single use items/clean dishes<br><br>

  • Chemicals are not stored on or above dishmachine

  • Chemicals are not stored on/above clean drain board or sanitize basin of dish sink

  • Chemicals are in labeled spray bottle/container

  • Chemicals are covered/sealed (excluding sanitizer bucket)

  • No bleach/unapproved pesticide/drain cleaner/ unapproved chemical present

  • No Scented hand lotion/unapproved hand soap/hand sanitizer present

  • Esteem Sani-NC (US)/UltraSan (CAN) not observed in store with high-temp dishmachine

Sanitizer Buckets and Bar Towels

  • Sanitizer container is properly labeled

  • Proper test strips are available and free of water damage

  • Quat- solution between 200 and 400ppm

  • Chlorine- solution between 100 and 200ppm

  • No towels left sitting on counters/shelves/on or in sink

  • In container with sanitizer solution

  • Large red sanitizer bucket not stored on counter or in sink

  • Clean towels/linens not stored with chemicals or a contamination potential/stored at least 12” away from any contamination potential

Handwashing

Handwashing taking place at appropriate times

  • After wiping hands on apron

  • After handling trash

  • After coughing/sneezing into hands

  • After touching face/hair/skin

  • After eating/drinking

  • After breaks

  • After handling dirty dishes or equipment

  • After blowing nose

  • After cleaning tasks

  • Before starting shift

  • Before putting gloves on

  • After using restroom

  • Partners washing hands are using soap and proper technique (incl. 10-15 second scrub)

Documentation

  • Food service permit is current (note expiration date)

  • One partner in charge per store with valid food safety certification , or more if your jurisdiction requires it

  • All partners have valid food worker cards if required

  • Allergen certification adequate per jurisdiction (MA)

  • Allergen Poster present in BoH

  • Heimlich maneuver signage posted where required (CA, CT, GA, MI, MD, NJ, NY, TX)

  • Most recent Health inspection report posted or on file

  • Most recent pest report is within 60 days/and available for review

  • Temp log complete, no entries missing/when required, corrective action noted

Food Safety and Partner Habits

Food Handling & Food Safety

  • Partner food/beverage is not stored on shelving next to dry goods, clean smallwares, or single use items shelving and at least 12” below and away

  • No Drinking/Eating (or evidence of) in food storage/food prep area

  • Partner belongings are not stored while partner is not scheduled to work

  • Partner belongings are not stored with dry goods, clean smallwares and/or clean linens on metro shelving and at least 12” below and away

  • Partners are not touching pastries/sandwiches/beverage ingredients/mouth contact parts of items with bare hands

  • Hot water available in the store (100- 120F/38-49C)

  • No sewage back up in store

  • Partner in charge can identify all smallwares that need to be washed, rinsed, and sanitized every 2 hours (ice scoops, in-use utensils, pitcher, spoons, lids)

  • Partner in charge knowledgable of proper dishwashing procedures-Wash, Rinse, Sanitize, then Air Dry

Pest Control

  • No evidence of mice/rats, flying insects, cockroaches, ants

Partner Uniforms

  • Aprons/cloths are clean and do not have more than one shift's accumulation of spills and splashes

  • Long hair beyond shoulder length is tied back/hair restraints are worn per jurisdictional requirement

  • Partner hands are cleanable, (reference partner handbook, acrylic nails, hand wrap/cast and jewelry)

Partner Health

  • Not working with severe chest congestion/severe runny nose

  • Not working with acute diarrhea/ vomiting/jaundice

  • Not working with fever/chills

  • Not working with any exposed infected lesion on hand/wrist/arm

  • Exposed bandages on hand/wrist are covered by single use glove

Operations

Operations

Exterior of the Store

Drive Thru Lane

  • Drive thru menu boards/speakers are clean

  • Drive thru lane does not have trash/cigarettes on ground

  • Drive thru window is closed when no cars are in queue

  • Drive thru trash can is not overflowing

  • Drive thru equipment in good repair

  • Drive thru window is closed when no cars are in queue

Entrance and patio of the Store

  • Doors/Windows below 12 feet clean

  • Exterior door is not left open without air<br>curtain operating

  • Sidewalk/patio have no recent spills/no excessive trash on the ground

  • Trash can(s) are not over flowing

  • Tables/chairs are clean and in good repair

  • Umbrellas clean and in good repair

  • Building awnings/soffit in good condition/not weathered

  • Exterior walls in good repair

  • Awnings not excessively dirty

Café: Entrance and Customer Seating Area

  • Walk off mat clean

  • Walk off mats in good repair

  • Door threshold is clean

  • Doors are in good repair and rodent proof

  • No Smoking signage posted at all customer entrances (leading outdoors) and patio seating (NA - CA, FL, CO)

  • Café ledges clean and windows below 12 feet are clean

  • Windows above 12 feet clean

  • Café Ceiling/Ducting/Lighting/Vents below 12 feet clean and lights are not out or missing

  • No dust build up/splatter on 12.8 ceiling/vents/lighting in FOH above 12 feet

  • Café chairs/tables/lamps clean and in good<br>repair

  • Café floor fixtures (baskets/newspaper stands/black apron rack) are clean

  • Café retail shelving clean

  • Retail shelving not damaged

Condiment Bar

General Cleanliness and Condition

  • Condiment bar is free of excessive spills

  • No build up under napkin holders/in trash cabinet/under trash ring/under 11.1 sugar/sweetener pack container

  • No encrusted buildup in sugar/sweetener pack container

  • Condiment/stir stick containers clean

  • Condiment bar service plane is not excessively worn and is free of scuffs and gouges

  • Cabinet facings/hinges in good repair

  • Condiment bar is free of paint peeling

  • Cabinet with trash can is clean

  • Shelving not damaged

  • Check floors, walls, countertops, ceilings (refer<br>to page 8)

Smallwares

  • Condiment bar shaker tops are not dented or<br>otherwise damaged

  • All condiment bar shaker(s) labeled

  • Condiment bar shakers/carafes labels are not 1.1 peeling/worn/not readable

  • Exterior door is not left open without air curtain operating

  • Sidewalk/patio have no recent spills/no excessive trash on the ground

  • Trash can(s) are not over flowing

  • Tables/chairs are clean and in good repair

  • Umbrellas clean and in good repair

  • Building awnings/soffit in good condition/not weathered

  • Exterior walls in good repair

  • Awnings not excessively dirty

Restrooms

Fixtures and condition

  • Restroom fixtures clean (Hand sink / faucets/toilet/mirror/air fresheners/handrails/baby changing table)

  • Restroom faucets/drainpipes are not dripping/secure/free of damage

  • Approved soap/paper towel dispensers properly stocked and working

  • Soap is not stored in caramel bottle/syrup bottle at hand sink

  • Handwashing signs are present at hand sinks

  • Hand sink(s) have warm water 100-120 °F (38-49 °C)

  • Restroom fixtures are in good repair and free of graffiti (Handsink / faucets / toilet / mirror/ baby changing table/doors)

  • Paper towel/soap/toilet paper dispensers/sconce shade/garbage cans are in good repair and free of graffiti

  • Toilet tissue is loaded into the dispenser

  • No odor present

General Cleanliness

  • Restroom ceiling/lighting/walls in good repair with no graffiti present

  • No Smoking signage posted in restrooms where required (NYC & NM)

  • Food/food contact equipment not stored in restroom

Pastry Case General Food Safety

  • Ambient pre-packaged RTE food within code date at the POS

  • All products within the pastry case have signage

  • Allergen Signage present in pastry case

  • Warming display signage present 'For Display Only' (where applicable)

  • Non-PHF RTD within code date

  • Sandwiches/Boxes/Salads/Fruit Cups/Yogurt/Yogurt Parfaits within expiration date

  • Product is not stored over front vents in the RTD&E case

  • Stored multi-day pastries dated and within code date

  • Food items stored protected, approved food covering used (indicate product improperly stored)

  • Butter/Cream Cheese are not stored at room temperature in the upper portion of the pastry case

  • Potentially hazardous samples are actively sampled and not left at room temperature

  • No product above 41°F (Canada 40°F/4°C) in RTD/E case

"Hand Sinks (FOH and BOH) Accessible and used properly "

  • Handwashing is not taking place in FOH dump sink (and dedicated hand sink present)

  • Dumping or rinsing is not taking place in dedicated hand sink

  • Access to hand sink is not blocked by trash cans/product

  • Smallwares/Product/food/drinks are not stored in or on designated hand sink

  • Hand sink/faucet is clean

  • Faucets/drainpipes are not dripping/secure/free of damage

All hand sinks properly stocked soap/paper towel dispenser functioning properly

  • Approved soap/paper towel dispensers properly stocked and working (

  • Approved soap/paper towel dispensers properly stocked and working (

  • Soap is not stored in caramel bottle/syrup bottle at hand sink

  • No Scented hand lotion/unapproved hand soap/hand sanitizer present

  • Handwashing signs are present at hand sinks

  • Hot water available in store at hand sink 100-120°F (38-49 °C)

"Warming Station Smallwares "

  • For-here cups and plates are not chipped/cracked

  • For-here serveware stored clean

  • Cutlery free of rust and not bent

  • Warming tongs/knives are free of multiple dried on product build up

  • In-use tongs stored on a clean cutting board or other clean surface

  • Utensil holder not rusting/in poor repair

  • Cutting boards are free of visible dried build up in grooves

  • Food contact items are from an approved source and food grade

  • Silverware/unwrapped plasticware stored handles up

  • Silverware/ unwrapped plasticware not Stored with handles in multiple directions if laid flat

  • Silverware/ plasticware stored in clean container

  • Plexi cubes not cracked/chipped

  • In use plexi cubes are clean

Oven

  • Warming oven interior/hinges/back of oven clean/under tray

  • Oven tray is not cracked/chipped

  • Warming oven exterior/vents clean

"Check floors, walls, countertops, ceilings (refer to page 8) Check refrigerator condition and cleanliness (refer to page 9) "

  • Non-PHF food within code date

  • PHF foods within code date

  • Food items stored protected, approved food covering used (indicate product improperly stored)

  • Food contact items properly stored

"Brewing Station/Backline Fixtures and condition "

  • Faucet fixtures secure/free of damage/not dripping (including drainpipes)

  • Sink/faucet is clean

  • Sink/drain pan sealed to counter top

Equipment

  • Coffee Brewer maintained clean

  • Coffee grinder and scale maintained clean

  • Clover machine maintained clean

Smallwares

  • Spoodle/coffee scale scoop clean and free of chips/dents

  • Spoodle stored in a clean designated storage container

  • Tea tongs are stored in a clean designated storage container

  • 8 qt. cubes/lids are free of adhesive build up/stains/scratches/chips

  • Coffee filters stored covered and protected

  • Food contact items not stored under dripping condensate or sewage lines

  • Food contact items are from an approved source and food grade

  • Stored smallwares are clean

  • Clean smallwares stored covered/inverted/on a clean surface

  • Clean smallwares stored separated from non -food related items

  • Unpackaged cups/lids are stored inverted and in plexi cubes

  • Plexi cubes not cracked/broken/no peeling tape

  • In use plexi cubes are clean

  • Single use cups/lids/reusable cups are free of splash/splatter and stored away from splash range of sinks

  • Exposed lids store sip side up

  • Sample cups stored protected

  • Pour Over Brewing smallwares are clean and free of damage

  • Pour over brewing coffee scoop stored in clean designated container.

  • Pour over Brew graduated pitcher stored inverted

  • Airpots not chipped/excessively dented

  • Clover whisk and scraper clean, stored properly

Food

  • Food items stored protected, approved food covering used (indicate product improperly stored)

  • Food items not stored under dripping condensate or sewage lines (specify location)

Coffee

  • Ground coffee and whole bean coffee stored protected

  • Tea and whole bean coffee (including 5 pound bullets) is dated and within code date

Drive thru

Operations

"DTO General Cleanliness and Condition "

  • Drive thru window area clean handoff plane/window ledges/register area

  • Drive thru window is not left except during window interactions

  • Faucet fixtures secure/free of damage/not dripping (including drainpipes)

  • Cream dispenser clean

  • Check floors, walls, countertops, ceilings (refer to page 8)

  • Drive-thru display and equipment clean

Under counters

  • Gaskets clean and in good repair

  • Food items stored protected, approved food covering used (indicate product improperly stored)

  • Non-PHF RTD dated and within code date

  • Ambient pre-packaged RTE food within code date

  • Cream dispenser labeled with contents on exterior of unit

  • Thermometer does not have any breaks or gaps in the red gauge" line " in front

  • Cream dispenser is not above 41°F (Canada 40°F/4°C) not expired

"Espresso Bar Equipment "

  • Bar ice bins/caddies is absent of mold/slime build up

  • Bar ice bins/caddies covered and protected

  • Blender Pitcher Rinser (BPR) clean/no leaks from base or unit

  • Espresso Machine Clean top, sides, underneath, no dust or buildup

  • Espresso machine food parts clean-bean hopper clean and not damabed, and espresso pour spout clean and not damaged

  • Espresso machine steam wand and area above steam wand is free of dried on/encrusted build-up

Food

  • Milk/soy within code date

  • Steaming pitchers are labeled with product type and correct pitcher used when steaming beverage

  • Bar vanilla/chocolate/cinnamon/ sugar/cinnamon dolce/pumpkin spice powder shaker(s) labeled

  • Bar caramel/mocha squeeze bottles labeled

  • Food items stored protected at the bar, approved food covering used (indicate product improperly stored)

  • Food contact items are from and approved source and food grade

  • Food items not stored under dripping condensate or sewage lines at the bar

  • Samples not left uncovered on counter at the bar/handoff plane

  • PHF are not left on counter above 41°F (Canada 40°F/4°C) (milk/soy/Frappuccino/ whipped cream )

  • PHF samples are not left on the counter at room temperature

  • Beverage syrups within code date and dated - list flavor

  • Sauces (specify product) within code date and dated

  • Powders/mocha with in code date and dated

  • Whole bean coffee within code date (including 5 lb bullets)

  • Milk and Soy is not below 150°F/65.5°C

  • Milk is never re-steamed/no new milk added to steamed milk

Sanitizer and Wiping Cloths

  • No wiping cloths left sitting on counters/shelves/on or in sink

  • Wiping cloths are stored in container with sanitizer solution

Smallwares

  • Food contact items not stored under dripping condensate or sewage lines at the bar

  • Bar area stored smallwares put away clean

  • Bar area clean smallwares stored covered/inverted/on a clean surface

  • Bar area clean smallwares stored separated from non-food related items

  • Bar area smallwares have no peeling stickers/tape/adhesive residue

  • Single use cups/lids/reusable cups are free of splash/splatter and stored away from splash range of sinks

  • Exposed lids store sip side up

  • Sample cups stored protected

  • Splash sticks stored siren-side up

  • Ice scoops at bar are stored in clean designated storage container between use

  • Ice scoops at bar are free of chips/handle is not broken

  • Ice scoops are clean and free of splatter and adhesive build up, sanitized every 2 hours

  • Steaming pitchers/spoons are free of permanent milk build-up

  • Steaming pitchers/thermometers are rinsed after each use, sanitized every 2 hours

  • Dipper well does not contain any utensils/thermometers

  • Smallwares/sanitizer 2 hour timer is in place and running

  • In-use smallwares are washed, rinsed and sanitized every 2 hours.

  • All thermometers within calibration and are being used when required

  • Unpackaged cups/lids are stored inverted and in plexi cubes

  • Plexi cubes not cracked/broken/no peeling tape

  • In use plexi cubes are clean

"Cold Beverage Station General Cleanliness and Condition "

  • Blender(s)/housing clean

  • Blender shroud free of cracks or pieces missing

  • Blender Pitcher Rinser (BPR) clean including underside/no major leaks

Equipment

  • CBS ice bins/caddies/FoH ice machine is absent of mold/slime build up

  • CBS ice bins/caddies covered and protected

  • Thermometer does not have any breaks or gaps in the red gauge" line "

Smallwares

  • Ice scoops at CBS are stored in clean designated container

  • Ice scoops at CBS are free of chips and handle is not broken

  • Ice scoop is clean and free of splatter and adhesive build up, santized every 2 hours

  • Unpackaged cups/lids are stored inverted and in plexi cubes

  • Plexi cubes not cracked/broken

  • In use plexi cubes are clean

  • Single use cups/lids/reusable cups are free of splash/splatter and stored away from splash range of sinks

  • Exposed lids store sip side up

  • Sample cups stored protected

  • CBS pitchers/8 qt. cubes/lids are free of adhesive build up/stains/scratches or chips

  • Blender Pitchers/shakers/lids are free of stains/scratched/chips

  • In use banana tongs do not have multiple use build up and stored in a clean designated container

  • CBS for-here serveware cups/plates are not chipped/cracked and stored clean

  • In use blender pitchers and shaker lids stored properly/blender pitchers and shakers not stored stacked on top of another/pitcher or shaker lids not stored on the bottom of the overturned pitcher or shaker

Food

  • Dairy/Soy in reach in within date code

  • Tea and coffee pitcher(s) dated

  • Opened dry inclusion bags/pouches dated

  • CBS beverage syrups within code date and dated

  • CBS sauces/concentrates (specify product) within code date and dated

  • CBS powders/mocha with in code date and dated

  • Peeled bananas dated and within code date

  • CBS dry inclusions(DIDs)/protein powder/shakers labeled with contents

  • Caramel/mocha squeeze bottles labeled

  • Food items stored protected, approved food covering used (indicate product improperly stored)

  • In use banana tongs do not have multiple use build up and stored in a clean designated container

  • CBS for-here serveware cups/plates are not chipped/cracked and stored clean

  • In use blender pitchers and shaker lids stored properly/blender pitchers and shakers not stored stacked on top of another/pitcher or shaker lids not stored on the bottom of the overturned pitcher or shaker

"BOH Dry Storage General Cleanliness and Condition "

  • Shelving labeled and stocked appropriately

  • Items are not stored on floor preventing cleaning

  • Dry storage shelving clean

  • Water filtration system clean/no dust

  • No Dust build up/splatter on ceiling/vents/lighting in BOH over 12 feet

  • Doors are in good repair and rodent-proof

  • No bags of trash stored on floor in back room

  • Lid closed on back room wheeled trash can

Smallwares

  • Food contact items are from an approved source and food grade

  • Cambros or single use Coffee Travelers stored at least 6 (15 cm) off floor and not on merchandise risers/milk crates "

  • Cups, lids, napkins, pastry bags stored at least 6 (15 cm) off floor and not on merchandise risers/milk crates "

  • Clean smallwares stored clean and inverted on a clean surface or covered, not mingled with non-food contact items

  • Food scoops (non-ice) stored in a clean, designated container or in the food with handle extended

Food

  • Stored thawed multi-day pastries dated and within code date

  • Packaged coffee/unopend soy/juice VIA/syrups/other within code date

  • RTD beverage/whole bean coffee/packaged food/pastry for donation stored at least 6 (15 cm) off floor "

  • Dairy/Soy in reach in within date code

  • Food not stored on top of turned over milk crates/brown merchandise risers /FOH retail shelving/pastry trays on the floor, approved food covering used

  • Partner food/beverage is not stored on shelving next to dry goods, clean smallwares, or single use items and at least 12” below and away

  • No Drinking/Eating (or evidence of) in food storage/food prep area

Mop Sink Area

  • Mop sink area clean

  • No strong odors from drain

  • Wet floor signs/brooms/dust pans/vacuums/mop bucket clean and mop not stored in dirty water

  • Trash can(s) not over flowing

"BOH Refrigeration Equipment Food "

  • Check refrigerator/freezer condition and cleanliness

  • Dairy in BoH cooler is within code date

  • Trash can(s) not over flowing

  • Baskets clean and in good repair

  • No product above 41°F (Canada 40°F/4°C) In BoH refrigerator

  • Sandwiches/salads/yogurts are dated and within code date

Ice Machine

  • BOH ice machine has no mold/slime build up

  • BOH ice machine lid is closed

  • No evidence of paint peeling/rust on outside of ice machine

  • Interior of ice machine in good repair/free of damage and chips/gasket in good condition

  • BOH ice scoop is stored in designated storage container between use

  • BOH ice scoop is not chipped or handle broken and is clean and free of adhesive build-up

  • BOH ice scoop storage container/bucket interior clean

  • BOH ice bucket labeled Ice Only" "

  • BOH Ice bucket is free of chips/cracks

  • BOH ice bucket is not used for something other than ice

  • Ice machine exterior dirty

Partner Habits

  • Partner food/beverage stored in a labeled/lidded container on the bottom shelf /ledge of refrigerator/freezer

"Dishwashing Area General Cleanliness and Condition "

  • Flex drain hose not placed in sewer pipe

  • No sewage back up present in facility

  • Dish sink/sprayer clean

  • No soft sponges/magic eraser-like pads in food prep area/dish area

  • Approved scouring pad/brushes are free of damage

  • Clean drain board free of anything other than clean dishes

  • WASH/RINSE/SANITIZE labels present/in correct order/free of damage

  • Dish compartment sink has hot water (120 °F in CA)

  • Faucets/drainpipes are not dripping/secure/free of damage

  • Shelving above dish sink clean

  • No towels left sitting on counters/shelves/on or in sink

  • Check floors, walls, countertops, ceilings

Dishmachine

  • Dishmachine and dishmachine door is clean

  • At least ½” of Supra is present in the auto feed container of detergent/pump for Supra available in stores without red auto-feed tube

  • Rinse cycle did reach 180°F on panel read-out for high temp machine (HTM)

  • Sani-NC (US)/UltraSan (CAN) is present in auto feed container for low temp machines

  • Chlorine sanitizer concentration is 50-200ppm for low temp dishmachine only

  • Clear auto-feed tube is not in Supra (clear is for chlorine sanitizer low temp machines only)

  • Rinse-Aid auto-feed (blue) tube coiled and tucked behind machine

Signatures

  • Feed back

  • Sm or supervisor signature

  • Dm 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.