Food Establishment Inspection Report
Establishment Name:
Score:
Establishment ID:
Foodborne Illness Risk Factors and Public Health Interventions
Date:
Status Code:
Time In:
Time Out:
Risk factors: Contributing factors that increase the chance of developing foodborne illness.
Public Health Interventions: Control measures to prevent foodborne illness or injury
Category#:
Compliance Status
Establishment Type:
Supervision
1
IN
OUT
N/A
PIC Present; Demonstration - Certification by accredited
program and perform duties
Employee Health
2
Instructions:
3
1. Fill in the information below for the
Food Establishment:
Location Address:
City:
State: North Carolina
County:
4
5
Permittee:
Telephone:
Inspection
Re-Inspection
Wastewater System:
Municipal/Community
On-Site System
Water Supply:
Municipal/Community
On-Site Supply
8
IN=In Compliance, OUT=Not in compliance
N/O=Not Observed, N/A=Not Applicable
9
10
11
12
CDI= Corrected During Inspection
R=Repeat Violation
VR=Verification Required
IN
OUT
IN
OUT
IN
OUT
IN OUT N/A N/O
IN
OUT
IN
IN
OUT
OUT
IN
N/O
OUT
IN OUT N/A N/O
13
15
IN OUT N/A N/O
IN
OUT
IN
OUT
No discharge from eyes, nose, and mouth
17
19
20
21
22
IN OUT N/A N/O
IN OUT N/A N/O
IN OUT N/A N/O
IN OUT N/A N/O
IN OUT N/A N/O
IN OUT N/A N/O
IN OUT N/A N/O
Hands clean & properly washed
No bare hand contact with RTE foods or pre-approved
alternate procedure properly allowed
Handwashing sinks supplied & accessible
23
IN
OUT
N/A
Food obtained from approved source
Food received at proper temperature
Food in good condition, safe & unadulterated
Required records available: shellstock tags, parasite destruction
IN
OUT
N/A
26
North Carolina Department of Health & Human Services • Division of Public Health
Environmental Health Section • Food Protection Program
Page 1 of
Food Establishment Inspection Report, 7/2012
IN
IN
Proper disposition of returned, previously served, reconditioned, & unsafe food
IN
4 2 0
3 1.5 0
2 1 0
2 1 0
2 1 0
2 1 0
2 1 0
3 1.5 0
2 1 0
.2653
Proper cooking time & temperatures
Proper reheating procedures for hot holding
Proper cooling time & temperatures
Proper hot holding temperatures
Proper cold holding temperatures
Proper date marking & disposition
Time as a public health control: procedures & records
3 1.5 0
3 1.5 0
3 1.5 0
3 1.5 0
3 1.5 0
3 1.5 0
2 1 0
.2653
Consumer advisory provided for raw or undercooked foods
1 0.5 0
.2653
Pasteurized foods used; prohibited foods not offered
3 1.5 0
.2653, .2657
OUT
OUT
N/A
N/A
Food additives: approved & properly used
Toxic substances properly identified stored, & used
Conformance with Approved Procedures
27
1 0.5 0
3 1.5 0
Food-contact surfaces: cleaned & sanitized
Chemical
25
2 1 0
.2653, .2654
Food separated & protected
Highly Susceptible Populations
24
3 1.5 0
.2653, .2655
Consumer Advisory
4. Continue to page 2 for
“Good Retail Practices”.
3 1.5 0
.2652, .2653, .2655, .2656
Potentially Hazardous Food Time/Temperature
16
0
.2652, .2653
Proper eating, tasting, drinking, or tobacco use
Protection from Contamination
18
3. Click/check the appropriate boxes for CDI and/or R, VR.
OUT
Proper use of reporting, restriction & exclusion
Approved Source
14
2. Click/fill the appropriate circle for “IN, OUT, N/A, N/O”.
IN
Management, employees knowledge; responsibilities &
reporting
Preventing Contamination by Hands
7
OUT
2
.2652
Good Hygienic Practices
6
Zip:
IN
OUT
.2652
OUT
N/A
1 0.5 0
2 1 0
.2653, .2654, .2658
Compliance with variance, specialized process, reduced
oxygen packaging criteria or HACCP plan
2 1 0
CDI
R
VR
Food Establishment Inspection Report, continued
Establishment Name:
Establishment ID:
Good Retail Practices
Instructions, continued:
5. Click the appropriate circle to fill-in
for “IN, OUT, N/A, N/O”.
Good Retail Practices: Preventative measures to control the addition of pathogens,
chemicals, and physical objects into foods.
Compliance Status
28
IN=In Compliance, OUT=not in compliance
N/O=Not Observed, N/A=Not Applicable
29
30
6. Click or check the appropriate boxes for CDI and/or R, VR.
CDI= Corrected During Inspection
R=Repeat Violation
VR=Verification Required
Calculate the “Total Deductions”
and record.
31
32
33
34
OUT
IN
IN
OUT
OUT
N/A
Pasteurized eggs used where required
Water and ice from approved source
Variance obtained for specialized processing methods
IN
OUT
IN OUT N/A N/O
IN OUT N/A N/O
IN
OUT
IN
OUT
Proper cooling methods used; adequate equipment for
temperature control
Plant food properly cooked for hot holding
Approved thawing methods used
Thermometers provided & accurate
37
38
39
40
IN
IN
IN
IN
OUT
OUT
OUT
OUT
OUT
Food properly labeled: original container
41
42
43
44
Signature Block:
IN
IN
IN
IN
OUT
OUT
OUT
OUT
Utensils and Equipment
Person in Charge (Print)
45
46
Person in Charge (Signature)
47
IN
IN
IN
Regulatory Authority (Signature)
48
49
50
51
Contact Number:
Verification Required Date:
52
REHS ID:
53
54
No. of Risk Factor/
Intervention
Violations:
No. of Repeat Risk
Factor/Intervention
Violations:
IN
IN
IN
IN
IN
IN
IN
2
1
0
1 0.5 0
1 0.5 0
1 0.5 0
1 0.5 0
1 0.5 0
2
1
0
Insects & rodents not present; no unauthorized animals
Contamination prevented during food preparation, storage
& display
2
1
0
Personal cleanliness
2
1
0
1 0.5 0
Wiping cloths: properly used & stored
Washing fruits & vegetables
1 0.5 0
1 0.5 0
.2653, .2654
In-use utensils: properly stored
1 0.5 0
Utensils, equipment & linens: properly stored, dried, &
handled
Single-use & single-service articles: properly stored & used
Gloves used properly
1 0.5 0
1 0.5 0
1 0.5 0
.2653, .2654, .2663
OUT
Equipment, food & non-food contact surfaces approved,
cleanable, properly designed, constructed, & used
2
OUT
Warewashing facilities: installed, maintained, & used; test
strips
1 0.5 0
OUT
Physical Facilities
Regulatory Authority (Print)
1 0.5 0
.2652, .2653, .2654, .2656, .2657
Proper Use of Utensils
9. Continue to page 3 for “Comment
Addendum to Food Establishment
Inspection Report”.
OUT
OUT
OUT
OUT
OUT
OUT
OUT
VR
.2653
Prevention of Food Contamination
IN
R
.2653, .2654
Food Identification
36
8. Fill in “No. of Risk Factor Intervention Violations” and “No. of
Repeat Risk Factor Intervention Violations”.
IN
CDI
.2653, .2655, .2658
Food Temperature Control
35
7. Sign and complete “Signature Block” .
OUT
Safe Food and Water
Non-food contact surfaces clean
1
0
1 0.5 0
.2654, .2655, .2656
Hot & cold water available; adequate pressure
Plumbing installed; proper backflow devices
Sewage & waste water properly disposed
Toilet facilities: properly constructed, supplied & cleaned
Garbage & refuse properly disposed; facilities maintained
Physical facilities installed, maintained & clean
Meets ventilation & lighting requirements; designated areas
used
2
1
0
2
1
0
2
1
0
1 0.5 0
1 0.5 0
1 0.5 0
1 0.5 0
Total Deductions:
North Carolina Department of Health & Human Services • Division of Public Health
Environmental Health Section • Food Protection Program
Food Establishment Inspection Report, 7/2012
Page 2 of
Comment Addendum to Food Establishment Inspection Report
Establishment Name:
Location Address:
City:
State: NC
County:
Zip:
Wastewater System:
Water Supply:
Municipal/Community
Municipal/Community
On-Site System
On-Site Supply
Permittee:
Telephone:
Establishment ID:
Visit
Verification
Name Change
Status Change
Pre-Opening Visit
Other _____________
Date:
Status Code:
Category#:
Temperature Observations
Item/Location
Temp
Item/Location
Temp
Item/Location
Temp
Observations and Corrective Actions
Item Number
Violations cited in this report must be corrected within the time frames below, or as stated in sections 8-405.11 of the food code.
Person in Charge (Print & Sign):
Date:
Regulatory Authority (Print & Sign):
Date:
REHS ID: North Carolina Department of Health & Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
N.C. Department of Health and Human Services is an equal opportunity employer and provider.
Page
of
Food Establishment Inspection Report, 7/2012