Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Exterior Grounds/ Walking Surfaces
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Are parking lots/sidewalks free of slip, trip and fall hazards?
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Are stairs/ramps in good condition and provided with appropriate handrails?
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Are curbs in good condition and not crumbling?
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Is exterior lighting adequate throughout premises? Is lighting bright enough to clearly see at night?
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Are the edges of outdoor steps marked with white or bright yellow paint to increase step visibility at night?
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Have all potholes, uneven walkways or parking areas been patched to eliminate falling hazards?
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If any gas pumps are out of order, are they labeled properly?
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TRASH: No accumulations of trash? Dumpsters outside have lid when not in use? Fire damper doors in working condition?
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Misc/Other
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Misc/Other
Interior- Front of Store
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Are water absorbent mats used at all entrances?
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Are mats in good condition without curled edges, tears, and unlevel areas
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Are interior floor surfaces in good condition?
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Are floors dry and clear of debris?
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Is there a spill clean-up procedure in place with spill kits?
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Are “Caution Wet Floor” signs available used for freshly mopped areas or spills?
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If wet floor signs were present during the time of visit, were they put away once the floor was dry?
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Is there a mat in front of the refreshment station?
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Is the general housekeeping adequate and not presenting any tripping hazards?
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Are walking areas free of appliances or extension cords?
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Are the aisle ways clear of boxes and excess materials?
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ATM security- are there cameras present and is the ATM located in a visible area?
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Misc/Other
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Misc/Other
Food Handling
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Are proper food handling procedures in place?
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Are employees washing hands before and after handling food? Are hand washing signs present?
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Are disposable gloves worn when handling food and being changed between handling customer transactions?
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Are gloves available when handling hot objects?
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Are employees trained on proper knife usage?
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Is there designated knife storage and are knives being put away when not actively being used?
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Is there a deep fat fryer present? If so, is there at least 18 inches of clearance (or a baffle) if positioned next to an open flame?
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Is a properly rated K class fire extinguisher nearby and in working order?
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Are all hoods, exhaust ducts and fans clean and free of grease and inspected every 3 months?
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Is there an ANSUL fire suppression system in place and inspected at least every 6 months?
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Are all electrical appliances grounded and wiring in good conditions?
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Are electrical outlets near the sink on a ground fault circuit interrupter (GFCI)?
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Are all cooking and prep areas clean, sanitary, and orderly?
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Misc/Other
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Misc/Other
Restrooms
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Are the restrooms in a dry, clean and in sanitary condition?
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Is the towel dispenser and trash can located adjacent to the sink? (not across the room where customers drip water on the floor)
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Are there employee handwashing signs present?
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Misc/Other
Interior- Back of Store
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Is the general housekeeping adequate and not presenting any tripping hazards?
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Are wet floor signs available? Are they being used as appropriate?
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Are electrical panels clear at least 36 inches (no items being stored in front)? Are they closed?
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Is the floor in front of the ice machine kept dry and not leaking? Is there a mat present?
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Is there an eyewash station present? Is it inspected and not obstructed with clear access?
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Is there a sharps container? Is it property maintained?
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Is the dishwashing area floor dry and floor mats present?
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Are Safety Data Sheets provided and kept updated for all chemicals/products handled by employees?
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Are ladders in good condition without defaced/worn labels (Load Capacity), and without damage to rails, rungs, slip-resistant footing? Take photo of any ladder or step stool present***
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Are exterior doors equipped with peep holes?
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Storage areas- are heavy boxes not being stored on top shelves?
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Is cash properly secured and a safe being used to storage valuables?
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Misc/Other
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Misc/Other
Life Safety
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Are exit doors equipped with illuminated exit signs? Are they not blocked and clear of obstructions?
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Are exit doors equipped with panic hardware?
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Are exit signs properly displayed and illuminated?
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Are facilities equipped with emergency lighting?
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Are doorways/halls/aisles free from obstruction?
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Have emergency preparedness procedures been implemented, including staff training and drills?
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Have portable fire extinguishers been inspected annually and documented on the tag?
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Has a monthly visual check of the portable fire extinguishers been conducted and documented on the back of the tag?
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Are portable fire extinguishers charged and mounted properly on the wall for immediate access?
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Are portable fire extinguishers accessible and not blocked?
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Is there a fire suppression system in place? If so, is it properly inspected and maintained?
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Are all sprinkler heads provided with at least 18 inches of clearance?
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Are smoke detectors in place? Are they hardwired and being property maintained/ inspected?
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Misc/Other
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Misc/Other
Administrative
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Is there a safety orientation in place for new employees? Is it documented?
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Are there safety policies and procedures in place? Are they enforced?
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Are regular inspections of the facility conducted to recognize and correct hazards? Are they documented?
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Are incident investigations conducted when employees or customers are injured and is the investigation documented?
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Is there a Return-to-Work Program (Light Work Duty) in place for injured employees?
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Are appropriate employment posters including the OSHA poster displayed for employees to view?
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Is an adequate first aid kit provided and kept well stocked? Bodily Fluid Clean-up Kit available?
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Misc/Other
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Misc/Other
Security
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Are surveillance cameras installed and operable with full coverage for the exterior, interior and parking lot?
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Do the surveillance cameras record and have the ability to save and recall at least 30 days of information?
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Have 911 Panic Buttons been provided and located in an inconspicuous location at the cash registers?
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Are facilities protected by a UL listed burglar alarm system connected to a central station?
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Are all exterior fences in good condition?
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Are all delivery personnel and vendors monitored while onsite?
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Are there sigs of vandalism or graffiti?
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Misc/Other
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Misc/Other
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Is the public viewing monitor (CCTV) in working condition?
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Do you have an understanding of how to arm and disarm the alarm panel keypad?
FUELING STATIONS
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Is there an emergency shut off switch for gas lines?
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Are hoses inspected on a regular basis?
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Is a spill kit available for gasoline?
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Are fire extinguishers available and serviced?
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Are gas caps securely tightened on the ground?
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Is tamper proof tape on each of the fueling stations?
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Are gas pumps primed every day?
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Are card readers inspected for data swiping devices?
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Misc/Other
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Misc/Other
Other Observations
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Are there any other observations to note?
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Are there any other observations to note?
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Are there any other observations to note?