Food Establishment Inspection Report ➤ Form A
Business Name: Operator: Page of
Address City ZIP Email Phone:
( )
General Health Record ID P/E Date Time In Office Time Activity Time Travel Time
PR SR : m : m : m : m
Red High Risk Factors
High Risk Factors are improper practices or procedures identified as the most prevalent contributing factors of foodborne illness or injury. Service
Circles indicate compliance status (IN, OUT, N/O, N/A) for each item.
IN = in compliance OUT = not in compliance N/O = not observed N/A = not applicable CDI = corrected during inspection R = repeat violation 128 Scheduled
Compliance Status CDI R PTS Compliance Status CDI R PTS 129 Return
Demonstration of Knowledge Potentially Hazardous Food Time/Temperature 126 Fld Pl Rvw
0100 IN OUT PIC certified by accredited program, or 5 1600 IN OUTN/A N/O Proper cooling procedures 25 130 Complaint
25 133 Illness / Inj.
compliance with Code, or correct answers
Proper Hot Holding Temperatures (<135°F)
0200 IN OUT Food Worker Cards current for all food workers; 5 1700 IN OUTN/A N/O
new food workers trained between 130°F to 134°F 5 134 Permit Inv.
1800 IN OUTN/A N/O Proper cooking time and temperature; proper 136 Field Educ.
Employee Health 25
0300 IN OUT Proper ill worker and conditional employee use of non-continuous cooking 127 Pre-Operat.
practices; no ill practices workers present; 25 1900 IN OUTN/A N/O No room temperature storage; proper use of time 25 106 HACCP
proper reporting of illness as a control _________
Preventing Contamination by Hands 2000 IN OUTN/A N/O Proper reheating procedures for hot holding 15
0400 IN OUT Hands washed as required 25 Proper cold holding temperatures (>41°F) 10 Results
0500 IN OUTN/A N/O Proper barriers used to prevent bare hand contact 25 2100 IN OUTN/A
between 42°F to 45°F 5
01 Satisfact
with ready to eat foods 02 Unsatisfact.
0600 IN OUT Adequate handwashing facilities 10 2200 IN OUT N/A Accurate thermometer provided and used to 5
evaluate temperature of PHF 03 Complete
Approved Source, Wholesome, Not Adulterated
Consumer Advisory 04 Incomplete
0700 INOUT Food obtained from approved source 15
5
_________
0800 IN OUT Water supply, ice from approved source 15 2300 IN OUTN/A Proper Consumer Advisory posted for raw or
0900 IN OUTN/A N/O Proper washing of fruits and vegetables 10 undercooked foods Action
1000 IN OUT Food in good condition, safe and unadulterated; 10 Highly Susceptible Populations 04 Suspend
approved additives
2400 IN OUTN/A Pasteurized foods used as required; prohibited 10 07 Approved
1100 IN OUT Proper disposition of returned, previously served, 10
unsafe, or contaminated food
foods not offered 10 Disapprv’d
1200 IN OUTN/A N/O Proper shellstock identification; wild mushroom ID; 5
Chemical 26 Fol/up Rq’d
parasite destruction procedures for fish 2500 IN OUT Toxic substances properly identified, stored, used. 10 00 N/A
Protection from Cross Contamination Conformance with Approved Procedures _________
1300 IN OUTN/A N/O Food contact surfaces and utensils used for raw 2600 IN OUTN/A Compliance with risk control plans, variances,
meat thoroughly cleaned and sanitized. No cross 15 plan of operation; valid permit; approved 10
contamination
procedures for non-continuous cooking
1400 IN OUTN/A N/O Raw meats below or away from ready to eat food;
species separated 5 2700 IN OUTN/A Variance obtained for specialized processing
methods (e.g., ROP) 10
1500 IN OUTN/A N/O Proper handling of pooled eggs 5
Blue Low Risk Factors
Low Risk Factors are preventive measures to control the addition of pathogens, chemicals, and physical objects into foods. Circled points indicate items not in compliance.
CDI R PTS CDI R PTS
Food Temperature Control Utensils and Equipment
2800 Food received at proper temperature 5 4000 Food and non-food surfaces properly used and constructed; 5
2900 Adequate equipment for temperature control 5 cleanable
3000 Proper thawing methods used 3 4100 Warewashing facilities properly installed, maintained, used;
Food Identification test strips available and used 5
3100 Proper labeling, signage 5 4200 Food – contact surfaces maintained, cleaned, sanitized 5 Red Critical Points
Protection from Contamination 4300 Non-food – contact surfaces maintained and clean 3
3200 Insects, rodents, animals not present; entrance controlled 5 Physical Facilities
3300 Potential food contamination prevented during delivery, 5 4400 Plumbing properly sized, installed, and maintained; proper 5 Blue Points
preparation, storage, display backflow devices, indirect drains, no cross-connections
3400 Wiping cloths properly used, stored; proper sanitizer 5 4500 Sewage, wastewater properly disposed 5
3500 Employee cleanliness and hygiene 3 4600 Toilet facilities properly constructed, supplied, cleaned 3
3600 Proper eating, tasting, drinking, or tobacco use 3 4700 Garbage, refuse properly disposed; facilities maintained 3 Total Points
Proper Use of Utensils 4800 Physical facilities properly installed, maintained, cleaned; 2
3700 In-use utensils properly stored 3 unnecessary persons excluded from establishment
3800 Utensils, equipment, linens properly stored, used, handled 3 4900 Adequate ventilation, lighting; designated areas used 2
3900 Single-use and single-service articles properly stored, used 3 5000 Posting of permit; mobile establishment name easily visible 2
Person in Charge (Signature)
(Printed Name)
Regulatory Authority (Signature)
(Printed Name)
PH-0078 (Rev. 5/13)
