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<br />
<br />DEP ARTl\1ENT OF BUS~"ESS A~1) PROFESSIONAL REGULATION
<br />Division of Hotels and Restaurants
<br />LEGAL NOTICE
<br />FOOD SERVICE INSPECTION REPORT page _ of _
<br />
<br />o Cat~ring 0 V~nding 0 T~mporary
<br />Month
<br />-< 0 Mobil~ food 0 Th~m~ Park 0 Sat~lIit~
<br />'-" Dis ensin Vehicle food Cart Service Unit
<br />Failure to comply with this Notice will result in an informal conference to determine whether your license will be suspended. revoked. or an administrative fine
<br />of up to $1,000 per violation imposed.
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<br />OWNER
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<br />.~~--';,~'0 2~(..::"'J:,
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<br />ADDRESS 2'i. i "{ "-
<br />RESTAURANT
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<br />{.-
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<br />HUHBER Of SEATS
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<br />o General
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<br />o Seating
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<br />ZIP-JaDE (option;'!
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<br />COlIn
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<br />BUSINESS
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<br />CONTROL NUHBER
<br />File Humber
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<br />0 o WARNING: o WARNING OF DIRECT NOTICE: o NOTICE TO SHOW CAUSE:
<br />..;''' Violations in the operation of your Violations in the operation of your Failure to be in compliance with this You may be issued a Notice to Show
<br />establishment must be corrected by the NEXT establishment must be corrected by: notice at any future inspection may result in Cause why sanctions shou Id not be assessed
<br />ROUTINE INSPECTION. I Month I Day I YmI a direct Notice to Show Cause. against your license.
<br /> I I 1199_1
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<br />FOOD
<br />D * 01 lotlrce: sotlnd condition, no spoilage
<br />D 02 Original container: properly labeled
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<br />FOOD PROTECTION
<br />o * 03 Potentially hazardotls food meets temperature requirements
<br />during storage, pr~paration, display, service, transportation
<br />Facilities to maintain product temperature
<br />Thermometers provided and conspicuotls
<br />Potentially hazardotls food propeny thawed
<br />Unwrapped and potentially hmrdotls food not melV!d
<br />Food protection during storage, preparation, display, service,
<br />transportation
<br />D 09 Handling offood (ice) minimized
<br />10 In use, food (ice) dispensing utensils propeny stored
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<br />PERSONNEL
<br />*" Personnel with infections restricted
<br />* /2 Hands washed and dean, good hygienic practices
<br />D 13 Clean dothes, hair restraints
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<br />FOOD EQUIPMENT AND UTENSILS
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<br />14 Food (ice) contactsurfms: designed, constructed, maintained,
<br />installed, located
<br />15 Hon-food contactsurf.lces: designed, constructed, maintained,
<br />installed, located
<br />16 Oi,hwashing facilities: designed, constructed, maintained, in-
<br />,tailed, located, operated
<br />17 Accurate thermometers, chemical test kits provided, gauge cod<
<br />(1/4" IPS valve)
<br />Pre-nushed, scrape , soaked
<br />Wash, rinse w.ater: dean, proper temp~ratur~
<br />lanitiution rinse: dean, temperature, concentration, expoSUR
<br />time; equipment, utensils sanitil~d
<br />Wipmg aoths: ean, use restricted, stoRd
<br />ood contact surfaces of equIpment and utensils dean, fm of
<br />abrasives, d~tergents
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<br />23 Hon-food contact surfaces of equipment and utensils dean
<br />24 Itorage, handling of dean equipment/utensils
<br />25 lingle-service artides, ltOrage, dispensing, used
<br />26 No re-use of single-service
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<br />WATER
<br />* 27 Water Sotlrce, safe: hor and cold under pressure
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<br />SEWAGE
<br />D * 28 lew.age and walle water disposal
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<br />PLUMBING
<br />D 29 Installed. maintained
<br />o . 30 Croll.connection, back ,iphonage, backOow
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<br />TOILET AND HANDWASHING FACILITIES
<br />. 31 Humber, convenient, uCOlsible, designed, installed
<br />D 32 Toilet rooms endosed, 'el~dosing doon, fixtures, good repair,
<br />dean; hand deaner, sanitary towehltillueslhand-drying devices
<br />provided, proper w..te receptadel
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<br />GARBAGE AND REFUSE DISPOSAL
<br />D 33 Containm or receptades, covered: adequate number, insec
<br />rodent proof. frequency, dean
<br />D 34 Outsid~ Slorage am endosures properly conSlructed, dean; con-
<br />trolled incineration
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<br />INSECT, RODENT, ANIMAL CONTROL
<br />D . 35 Prmnce of insectslrodents.Mer openingl protect~d, no birds,
<br />turtlel, other animals
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<br />FLOORS, WALLS AND CEILINGS
<br />D 36 f1oon: conltructed. drain~d. clean, good repair, covering in-
<br />stallation, dustless deaning methods
<br />D 37 Walls, ceilings, attached equipment: constructed, good repair,
<br />dean surfac~s, dustless deaning methods
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<br />Items marked with an ASTERISK * are areas of CRITICAL CONCERN in the operation of our establishment:
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<br />RECIPIENT'S NAME (PLEASE PRINT)
<br />
<br />/ acknow/etlre receipt of this inspection form 3//tI comments
<br />
<br />TITlE
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<br />REMINDER: Your license expires ~/-!~
<br />INSPECTOR'S NAME (PLEASE PRINT) TITlE.
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<br />~\ ,-- "- "
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<br />RECIPIENT'S SIGNATURE
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<br />EST ABlISHMENT TELEPHONE
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<br />DATE
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<br />SPR 22.015
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<br />LIGHTING
<br />38 lighting provided as required, fixtures shielded
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<br />VENTILATION
<br />39 Rooms and equipment-vented as required
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<br />DRESSING ROOMS
<br />40 Rooms dean, locken provided, facilities dean. located, used
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<br />OTHER OPERATIONS
<br />* 41 Toxic items propeny SlOled, labeled. uled, necessary
<br />D 42 Premises maintained, free of litter, unnecessary artides, dean.
<br />ing maintenance equipment propeny stored. Authorized per-
<br />lonnel
<br />o 43 Complete separation from Iivinglsleeping quartm. laundry
<br />facilities maintamed
<br />o 44 Clean, ,oiled linen properly ltOled
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<br />SAFETY
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<br />,. *45 Fire extinguishen-proper and sufficient
<br /> * 46 Exiting system-adequate, good repair
<br /> '<fT Electrical wiring-adequate, good repair
<br /> . 48 Gas appliances-propeny installed, maintained
<br /> * 49 Flammablolcombustible materials- ro erl ,tored
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<br />p p y
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<br />GENERAL
<br />Currentlicense-propeny displayed
<br />Other conditions-sanitary and safe operation
<br />Fals misleading Slatements-publish~d or advertised relating to
<br />food/beverage
<br />53 food management certification valid
<br />54 florida aean Indoor Air Act
<br />55 Automatic Gratuity Hotice
<br />56 Copy of Chapter 509. f10rida Statutes, available
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<br />INFORMATION
<br />57 Hospitality Education Program information provided
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<br />COMMENTS ON ADDENDUM
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<br />INSPECTOR'S SIGNATURE-
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<br />TIME
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<br />OFFICE TELEPHONE
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<br />DATE_.
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<br />ReVised 3/31/95
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