Food Establishment Inspection Report
Score:
Establishment Name:
Establishment ID:
Location Address:
City:
State: North Carolina
Zip:
County:
Permittee:
Telephone:
Inspection
Re-Inspection
Wastewater System:
Municipal/Community
On-Site System
Water Supply:
Municipal/Community
On-Site Supply
Date:
Status Code:
Time In:
Time Out:
Category#:
FDA Establishment Type:
No. of Risk Factor/Intervention Violations:
No. of Repeat Risk Factor/Intervention Violations:
Good Retail Practices
Foodborne Illness Risk Factors and Public Health Interventions
Risk factors: Contributing factors that increase the chance of developing foodborne illness.
Good Retail Practices: Preventative measures to control the addition of pathogens, chemicals,
and physical objects into foods.
Public Health Interventions: Control measures to prevent foodborne illness or injury
Compliance Status
OUT CDI R VR
Supervision
PIC Present; Demonstration - Certification by
accredited program & performs duties
Employee Health
3 IN OUT
Good Hygienic Practices
Preventing Contamination by Hands
6 IN OUT
7 IN OUT N/A N/O
8 IN OUT N/A
12 IN OUT N/A N/O
3 1.5 0
2 1 0
1 0.5 0
4 2 0
3 1.5 0
Food obtained from approved source
Food received at proper temperature
Food in good condition, safe & unadulterated
Required records available: shellstock tags,
parasite destruction
2 1 0
2 1 0
2 1 0
2 1 0
.2653, .2654
13 IN OUT N/A N/O Food separated & protected
14 IN OUT
Food-contact surfaces: cleaned & sanitized
Proper disposition of returned, previously served,
reconditioned & unsafe food
2 1 0
16
17
18
19
20
21
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
22 IN OUT N/A N/O
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
Consumer Advisory
23 IN OUT N/A
Consumer advisory provided for raw or
undercooked foods
Pasteurized foods used; prohibited foods not
offered
Conformance with Approved Procedures
27 IN OUT N/A
1 0.5 0
Food Temperature Control
31 IN OUT
Proper cooling methods used; adequate
equipment for temperature control
Food Identification
35 IN OUT
1
0
2
1
0
37 IN OUT
Contamination prevented during food
preparation, storage & display
2
1
0
38 IN OUT
39 IN OUT
40 IN OUT N/A
41 IN OUT
42 IN OUT
Personal cleanliness
Wiping cloths: properly used & stored
Washing fruits & vegetables
45 IN OUT
48 IN OUT N/A
49 IN OUT
50 IN OUT
51 IN OUT N/A
52 IN OUT
53 IN OUT
1 0.5 0
1 0.5 0
1 0.5 0
.2653, .2654
In-use utensils: properly stored
Utensils, equipment & linens: properly stored,
dried & handled
Single-use & single-service articles: properly
stored & used
Gloves used properly
Utensils and Equipment
54 IN OUT
2 1 0
2
.2652, .2653, .2654, .2656, .2657
Insects & rodents not present; no unauthorized
animals
Physical Facilities
1 0.5 0
2 1 0
1 0.5 0
1 0.5 0
1 0.5 0
36 IN OUT
47 IN OUT
3 1.5 0
1 0.5 0
.2653
Food properly labeled: original container
Prevention of Food Contamination
46 IN OUT
1 0.5 0
.2653, .2654
32 IN OUT N/A N/O Plant food properly cooked for hot holding
33 IN OUT N/A N/O Approved thawing methods used
34 IN OUT
Thermometers provided & accurate
2 1 0
.2653, .2654, .2658
Compliance with variance, specialized process,
reduced oxygen packaging criteria or HACCP plan
Variance obtained for specialized processing
methods
44 IN OUT
.2653, .2657
Food additives: approved & properly used
Toxic substances properly identified stored & used
30 IN OUT N/A
0
0
0
0
0
0
.2653
Chemical
25 IN OUT N/A
26 IN OUT N/A
1.5
1.5
1.5
1.5
1.5
1.5
.2653
Highly Susceptible Populations
24 IN OUT N/A
3
3
3
3
3
3
.2653, .2655, .2658
1 0.5 0
2 1 0
43 IN OUT
Potentially Hazardous Food Time/Temperature .2653
CDI R VR
Pasteurized eggs used where required
Water and ice from approved source
Proper Use of Utensils
3 1.5 0
3 1.5 0
OUT
28 IN OUT N/A
29 IN OUT
2 1 0
.2653, .2655
Protection from Contamination
15 IN OUT
3 1.5 0
.2652, .2653, .2655, .2656
Hands clean & properly washed
No bare hand contact with RTE foods or preapproved alternate procedure properly followed
Handwashing sinks supplied & accessible
Approved Source
N/O
0
.2652, .2653
Proper eating, tasting, drinking or tobacco use
No discharge from eyes, nose or mouth
4 IN OUT
5 IN OUT
2
.2652
Management, employees knowledge;
responsibilities & reporting
Proper use of reporting, restriction & exclusion
2 IN OUT
9 IN OUT
10 IN OUT
11 IN OUT
Safe Food and Water
.2652
1 IN OUT N/A
Compliance Status
1 0.5 0
1 0.5 0
1 0.5 0
1 0.5 0
.2653, .2654, .2663
Equipment, food & non-food contact surfaces
approved, cleanable, properly designed,
constructed & used
Warewashing facilities: installed, maintained &
used; test strips
Non-food contact surfaces clean
2
1
0
1 0.5 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
TOTAL DEDUCTIONS:
North Carolina Department of Health & Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
DHHS is an equal opportunity employer.
Page 1 of ____ Food Establishment Inspection Report, 3/2013
2
2
2
1
1
1
0
0
0
1 0.5 0
1 0.5 0
1 0.5 0
1 0.5 0
Comment Addendum to Food Establishment Report
Establishment ID:
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:
Inspection
Visit
Verification
Name Change
Status Change
Pre-Opening Visit
Other
Re-Inspection
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):
Regulatory Authority (Print & Sign):
REHS ID:
North Carolina Department of Health & Human Services • Division of Public Health • Environmental Health Section • Food Protection Program
DHHS is an equal opportunity employer.
Page ____ of ____ Food Establishment Inspection Report, 3/2013