FOOD SAFETY INSPECTION REPORT

AUDITOR: DATE: TOTAL SCORE

MANAGER: UNIT #:

FRANCHISEE: TIME IN:

STREET ADDRESS: TIME OUT:

in = in compliance; out = out of compliance; no = not observed

SECTION I - Risk Factors Points Deducted
POINT VALUE - 7 POINTS FOR EACH OPPORTUNITY - MAX POINTS 35 *( 8-13) 11 POINTS – CLOSEABLE
POTENTIALLY HAZARDOUS FOOD Directed Training (0 points)
1 in out no Holding of PHF 60-125ºF (15.5 – 51.7ºC) FOH BOH A
O Proper hot holding temperatures
O Proper cold holding temperatures B
2 in out no Proper cooking time and temperature BOH
3 in out no Proper reheating procedures for hot holding BOH VERMIN
4 in out no Proper cooling time and temperatures BOH 8* in out no Rodents/ Cockroaches - active FOH BOH
O Deep container O Mice or rats
O Covered container O Roaches
O No ice bath 9 in out no Flies - immediate risk FOH BOH
O Not stirred WATER and SANITIZING
PREVENTING CONTAMINATION 10 in out no Sanitizing - dishmachine/ dishsink FOH BOH
5 in out no Food in good condition, safe and unadulterated FOH BOH O Chemical sanitizer not available in restaurant
O Approved Source O High temperature sanitizing not occurring
6 in out no Employee health FOH BOH 11* in out no No water/ no hot water at 2 or more sinks FOH BOH
O Unprotected coughing or sneezing SEWAGE
O No discharge from eyes, nose, mouth 12* in out no Sewage backup - (includes toilets, drains, sinks,etc) FOH BOH
7 in out no Hands clean and properly washed FOH BOH O Dishroom O Restroom
O Not washing hands as needed O Line O Other
O Handwashing facilities supplied & accessible 13* in out no Toilets - no operable toilets FOH BOH
SECTION II - Risk Factors Points Deducted
POINT VALUE - 4 POINTS FOR EACH OPPORTUNITY - MAX POINTS 36
POTENTIALLY HAZARDOUS FOOD CHEMICAL
14 in out no Holding temperatures of PHF/TCS FOH BOH 24 in out no Toxic substances FOH BOH
O Improper hot holding 126-135ºF (52-57ºC) O Properly identified
O Improper cold holding 42-59ºF (5.5-15Cº) O Properly stored
O Food received at proper temperature O Properly used
15 in out no Diligent preparation BOH GOOD HYGIENIC PRACTICES
O Too much food being prepped 25 in out no Employee practices FOH BOH
O Food not being attended to in timely manner O Proper eating, tasting, drinking, or tobacco use
16 in out no Improper Thawing BOH O Drink/ food in designated place
O Room temperature O No barehand contact with RTE food
O Standing water O Improper glove use
O Not submerged in running water PROTECTION FROM CONTAMINATION
PROTECTION FROM CONTAMINATION 26 in out no Food contact surfaces - cleaned and sanitized FOH BOH
17 in out no Food Protected (containers) FOH BOH O Can opener O Scale
O Not covered in storage O Blender O Mixer
O Not labeled (non-descript food) O Slicer O Ice machine
O Not elevated 6" O Knife/ holder O Ice bin
18 in out no Food Protected (contamination) FOH BOH O Utensil/ holder O Soda Nozzle
O Washing fruits and vegetables O Plates O Soda Gun
O Using a cutting board on a trash can O Food processor O Tea nozzle
O Food prepared in unapproved area O Dicer O Cutting board
O Scoop buried in food O Food container - wet with residue/ unclean
O Prep sink not washed between uses 27 in out no Sanitizing - dishmachine/ dishsink FOH BOH
19 in out no Food Separated FOH BOH O ppm low O water temp too low
O Raw over ready-to-eat (RTE) O ppm high O water temp too high
O Raw poultry over other raw foods 28 in out no Plumbing installed; proper backflow devices FOH BOH
O Ice contaminated O Water and ice from approved source
23 in out no Handsinks not stocked FOH BOH 29 in out no Critical Handsinks fixture FOH BOH
O No soap O Handsinks inaccessible or blocked
O No towels O Sink inoperable or misused

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NAME: ADDRESS: DATE:

SECTION III - Good Retail Practices Points Deducted

POINT VALUE - 1 POINT FOR EACH OPPORTUNITY -
FOOD PROPER USE AND STORAGE
31 Spoilage/ mold on produce FOH BOH 47 Storage (low risk) FOH BOH
32 Pure food/ dented cans/ bad rim/ no spoils area FOH BOH O Utensil water <140/135ºF O Dipper well off
33 Improper inspection at delivery/ transportation FOH BOH O W edged utensils O Pans wet nested w/o residue
OPERATIONS O Inverted single-use item O Scoop handle touching food
34 Dispensers -soap/ towel broken FOH BOH 48 Unapproved type/ improper use/ improper installation FOH BOH
35 Employee hygiene & cleanliness FOH BOH O Tape on utensils O Crates used as shelf
O Missing hair restraints (hairnet or hat) O Foil lining equipment O Crates used to store items
O Soiled apron/ uniforms O Cardboard on floor O Food in plastic grocery bags
O Fake or painted nails/ jewelry on hands and arms O W et cloth under cutting board O Scoop w/o handle
O Employee chewing gum O Absorbent material lining shelves O Other:
37 Hazardous materials/ chemicals - low risk FOH BOH 49 W iping cloth : properly used and stored FOH BOH
38 Interior premises -storage of linen/ castoff FOH BOH 50 Sanitizer buckets - improper concentration/ test kit FOH BOH
39 Non food contact surfaces - unclean FOH BOH O QUAT / CL too high
O Shelves/ Racks O Gaskets O QUAT / CL too low
O Counters O Fryer cabinet O QUAT dispenser at improper level
O Bar refrigerators O Under grill O No test strips available
O FOH refrigerators O Oven O Wrong strips in use
O BOH refrigerators O Oven knobs 51 Therrmometer provided and accurate FOH BOH
O Fan guards O Ice maker lid O Not conspicuous/ visible O Improper use
O Dishmachine O Microwave O Not accurate O Not NSF approved
O Soda gun holder O Other: WALLS/ CEILINGS/ FLOORS
PHYSICAL FACILITY 52 Deterioration/ unapproved materials FOH BOH
40 Sink/ floor sink/ floor drain FOH BOH 53 Unclean floors, walls, ceiling FOH BOH
O Not clean O Floors
O Clogged/ slow draining O W alls
41 Supply line/ waste line FOH BOH O Ceiling
O No air gap O Standing water (floor)
O Not secure, poor installation VERMIN
O Leaking 54 Rodents/ cockroaches - no active population FOH BOH
42 No hot water - no immediate risk (1 sink) FOH BOH 55 Other insects (i.e. fruit & drain flies) - low risk FOH BOH
43 Hood - not clean/ disrepair/ missing/ gap FOH BOH 56 Open door/ air curtain/ window FOH BOH
44 Poor lighting FOH BOH TOILETS/ TOILET ROOMS/ DRESSING ROOMS
O Missing or broken light shield endcap 57 Toilet(s)-disrepair/ not clean/ tissue in dispenser FOH BOH
O Missing endcap 58 Toilet room doors not self-closing FOH BOH
45 Ventilation - unclean ceiling vent FOH BOH 59 Dressing room/ personal items FOH BOH
46 Condition - disrepair FOH BOH REFUSE/ PREMISES/ JANITORIAL
O Fry basket O Knives 60 Janitorial - supplies/ equipment/ tools in improper place FOH BOH
O Cutting boards O Utensils 61 Refuse containers/ exterior premises FOH BOH
O Wares O Gaskets O Trash receptacle
O Equipment O Shelves O Grease receptacle
O Plates O Other: O Exterior premises/ loading dock
SECTION IV - Administrative
NO POINTS SUBTRACTED FROM OVERALL SCORE FOR THIS SECTION
SIGNS/ PERMITS OTHER
62 Health permit not available for review 66 First Aid Kit 70 Pest control Date
63 Certification (Food safety manager) 67 Blood and Bodily Fluid Kit 71 Master Cleaning Schedule
64 Food handler card (where applicable) 68 Temperature Logs - # 14 Cycle 2 72 SDS Book Complete
65 Signs - handwash/ smoking/ choking 69 Pest traps Secure and away from food 73 Bright Color Bandages
SECTION V – Health Inspection
AUDITOR W ILL CAPTURE ANY OPPORTUNITY DEDUCTED AS A CRITICAL FROM THE HEALTH AUTHORITY AT EVERY INSPECTION

DATE: O Holding temperatures O Cross contamination O Thawing

SCORE: O Unstocked handsink O Food not labeled O Cooking
CITY State: O Handsink blocked O Food not elevated O Other:
Country O Improper handwash O Unclean equipment
SECTION VI - Other
Risk Management
76 Consumer Advisory on Menu
77 ALLERGENS
78 W et floor sign available/ covering wet area
79 Employees wearing slip resistant shoes [ OF ]
80 Other:

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NAME: ADDRESS: DATE:
TEMPERATURE CONTROL

Food type (PHFs) Temp. Violation Equipment Location Water Control Temp/PPM Violation Location Chemical
Y N Sanitizer bucket Y N
Y N Dishmachine Y N
Y N Dishsink Y N
Y N Handsink - food area Y N
Y N Handsink - restroom Y N
Y N Prep sink Y N
Y N Bar sink/ machine Y N
Y N Y N
Y N Y N
Y N Y N

Section I Opportunities - Call Brand Protection if 6, 8, 11-13 are observed

Violation #

Section II Opportunities - Indicate repeat violations

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NAME: ADDRESS: DATE:

FOOD SAFETY AND SECURITY REPORT

Section III Opportunities
Violation #

Section IV, VI & Additional Comments

63 Food Safety Certificates: OF managers
69 Last Pest Report Date: Comments:
71 MSDS:

Notes:

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NOTES