Title Page
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Conducted on
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Prepared by
Compliance Status: Out = not in compliance, IN = in compliance, NO = not observed, NA = not applicable, COS = corrected on site, R = repeat violation
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Priority Items (3 Points) violations Require Immediate Corrective Action not to exceed 3 days
Time and Temperature for Food Safety (F = degrees Fahrenheit)
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1. Proper cooling time and temperature?
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2. Proper Cold Holding temperature(41°F/ 45°F)
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3. Proper Hot Holding temperature(135°F)
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4. Proper cooking time and temperature.
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5. Proper reheating procedure for hot holding (165°F in 2 Hours)
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6. Time as a Public Health Control; procedures & records.
Approved Source
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7. Food and ice obtained from approved source; Food in good condition, safe, and unadulterated; parasite destruction
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8. Food Received at proper temperature
Protection from Contamination
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9. Food Separated & protected, prevented during food preparation, storage, display, and tasting.
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12. Management, food employees and conditional employees; knowledge, responsibilities, and reporting.
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10. Food contact surfaces and Returnables; Cleaned and Sanitized at_______ppm/temperature.
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11. Proper disposition of returned, previously served or reconditioned.
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13. Proper use of restriction and exclusion; No discharge from eyes, nose, and mouth
Preventing Contamination by Hands
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14. Hands cleaned and properly washed/ Gloves used properly
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15. No bare hand contact with ready to eat foods, Proper handling of ready to eat foods
Highly Susceptible Populations
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16. Pasteurized foods used; prohibited food not offered Pasteurized eggs used when required
Chemicals
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17. Food additives; approved and properly stored; Washing Fruits & Vegetables
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18. Toxic substances properly identified, stored and used
Water/ Plumbing
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19. Water from approved source; Plumbing installed; proper backflow device
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20. Approved Sewage/Waste water Disposal System, proper disposal, Grease Trap, Trip Tickets
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Priority Foundation Items (2 Points) violations Require Corrective Action within 10 days
Demonstration of Knowledge/ Personnel
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21. Person in charge present, demonstration of knowledge, and perform duties/ Certified Food Manager (CFM), Certificate Displayed
Safe Water, Recordkeeping and Food Package Labeling
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23. Hot and Cold Water available; adequate pressure, safe
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24. Required records available (shellstock tags; parasite destruction); Packaged Food labeled
Conformance with Approved Procedures
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25. Compliance with Variance, Specialized Process, and HACCP plan; Variance obtained for specialized processing methods; manufacturer instructions
Consumer Advisory
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26. Posting of Consumer Advisories; raw or under cooked foods (Disclosure/Reminder/Buffet Plate)/ Allergen Label
Food Temperature Control/ Identification
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27. Proper cooling method used; Equipment Adequate to Maintain Product Temperature
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28. Proper Date Marking and disposition
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29. Thermometers provided, accurate, and calibrated; Chemical/thermal test trips
Permit Requirement, Prerequisite for Operation
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30. Food Establishment Permit (Displayed, Current & Valid)
Utensils, Equipment, and Vending
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31. Adequate handwashing facilities: Accessible and properly supplied, used
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32. Food and Non-food Contact surfaces cleanable, properly designed, constructed, and used
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33. Warewashing Facilities; installed, maintained, used/Service sink or curb cleaning facility provided
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Core Items (1 Point) Violations Require Corrective Action Not to Exceed 90 Days or Next Inspection Whichever Comes First
Prevention of Food Contamination
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34. No Evidence of Insect contamination, rodent/other animals
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35. Personal Cleanliness/eating, drinking or tobacco use
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36. Wiping Cloths; properly used and stored
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37. Environmental contamination
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38. Approved thawing method
Proper Use of Utensils
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39. Utensils, equipment, & linens; properly used, stored, dried, & handled/ In use utensils; properly used
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40. Single-service & single-use articles; properly stored and used
Food Identification
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41. Original container labeling(Bulk Food)
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42. Non-Food Contact surfaces clean
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43. Adequate ventilation and lighting; designated areas used
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44. Garbage and Refuse properly disposed; facilities maintained
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45. Physical facilities installed, maintained, and clean
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46. Toilet Facilities; properly constructed, supplied, and clean
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47. Other Violations
