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ESTABLISHMENT NAME: OPERATOR’S NAME: Address: T/V/C County: Zip Code: TIME END FACILITY CODE TIME BEGAN 1A 1B 1C 1D 1E 1F 1G 1H 2A 2B 2C 2D 2E 3A 3B 3C 4A 4B 4C 5A 5B 5C 5D 5E 6A 6B 7A 7B 7C 7D 7E 7F 7G 7H 8A 8B 8C 8D 8E 8F 8G 9A 9B 9C 9D 10A 10B 11A 11B 11C 11D 12A 12B 12C 12D 12E 13A 13B 14A 14B 14C 15A 15B 15C 15D 16 Number of Red Violations Found Total Red Violations Not Corrected Number of Blue Violations Found Item Number SIGNATURE OF INSPECTOR RECEIVED BY (SIGNATURE) Yes No Date of Service Month Day Year hr hr min min INSPECTION REINSPECTION PRE-OPERATIONAL HACCP ONLY COMPLAINT INCIDENT ILLNESS FIELD VISIT Service Type: NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Community Environmental Health and Food Protection SUBPART 14-1 Reinspection Required Capacity Time spent conducting service Office Code: Operation ID: Corrections/Violations DOH-192 (12/11) Food Service Establishment Inspection Report NYSDOH LHD/HIN 60555 ---PAGE BREAK--- PART 1 – CRITICAL ITEMS FOODS ADULTERATED OR RECEIVED FROM UNAPPROVED SOURCES. 14-1.10, 1.31, 1.33, 1.34, 1.120, 1.121, 1.122** A. Unpasteurized milk and milk products used Water/ice: unsafe, unapproved sources, cross connections C. Home canned goods, or canned goods from unapproved processor found on premises D. Canned goods found in poor condition (Leakers, severe dents, rusty, swollen cans) E. Meat and meat products not from approved plants F. Shellfish not from approved sources, improperly tagged/labeled, tags not retained 90 days G. Cracked/dirty fresh eggs, liquid or frozen eggs and powdered eggs not pasteurized H. Food from unapproved source, spoiled, adulterated on premises 2. FOODS NOT PROTECTED FROM CONTAMINATION, TEMPERATURES NOT MEASURED. 14-1.10, 1.31, 1.40, 1.41, 1.43, 1.71, 1.85, 1.110 A. Prepared food products, contact equipment or work surfaces which have had prior contact with raw foods and where washing and sanitizing of the food contact surface has not occurred to prevent contamination B. Food workers prepare raw and cooked or ready to eat food products without thorough handwashing and sanitary glove changing in between C. Cooked or prepared foods are subjected to cross-contamination from raw foods Unwrapped/potentially hazardous foods are reserved E. Accurate thermometer not available or used to evaluate potentially hazardous food temperatures during cooking, cooling, reheating and holding 3. FOODS NOT PROTECTED FROM CONTAMINATION BY WORKERS. 14-1.10, 1.70, 1.71, 1.72, 1.80 Food workers prepare foods when ill with a disease transmissible by foods such as: diarrhea ("stomach flu"), hepatitis, acute respiratory infection, vomiting or have infected cuts or burns on their hands B. Food workers do not wash hands thoroughly (generate lather) after visiting the toilet, coughing, sneezing, smoking or otherwise contaminating their hands C. Food workers do not use proper utensils (tongs, spoons, spatulas, sanitary gloves) to eliminate bare hand contact with cooked or prepared foods 4. FOODS NOT PROTECTED FROM CONTAMINATION BY OTHER SOURCES. 14-1.10, 1.31, 1.40, 1.60, 1.90, 1.91, 1.92, 1.100 Toxic chemicals are improperly labeled, stored or used so that contamination of food can occur B. Acid foods are stored in containers or pipes that consist of toxic metals (antimony, cadmium, copper, zinc, lead) Foods or food area/public area contaminated by sewage or drippage from waste lines. *IMMINENT HEALTH HAZARD – REFER TO 10 SECTION 14-1.10 **NUMBER LISTED REFER TO 10 SUBPART 14-1 IMPROPER COOLING AND REFRIGERATED STORAGE OF POTENTIALLY HAZARDOUS FOODS. 14-1.10, 1.35, 1.40, 1.44 A. Potentially hazardous foods are not kept at or below 45°F during cold holding, except smoked fish not kept at or below 38°F during cold holding. Actual T oF B. Potentially hazardous foods are not cooled by an approved method where the food temperature can be reduced from 120°F to 70°F or less within two hours and 70°F to 45°F within four hours. (Potentially hazardous foods that are cooling may be uncovered during the cooling period) Actual T oF, Time Hours C. Potentially hazardous foods are not stored under refrigeration except during necessary preparation or approved precooling procedures. (room temperature storage) Actual T oF D. Potentially hazardous foods such as salads prepared from potatoes or macaroni are not prepared as recommended using prechilled ingredients and are not prechilled to 45°F or less as recommended before they are stored on buffet lines. Actual T oF E. Enough refrigerated storage equipment is not present, properly designed, maintained or operated so that all potentially hazardous foods are cooled properly and stored below 45°F as required. 6. IMPROPER HOT HOLDING OF POTENTIALLY HAZARDOUS FOODS. 14- 1.10, 1.40, 1.45 Potentially hazardous foods are not kept at or above 140°F during hot holding. Actual oF B. Enough hot holding equipment is not present, properly designed, maintained and operated to keep hot foods above 140oF 7. INADEQUATE COOKING AND REHEATING OF POTENTIALLY HAZARDOUS FOODS. 14-1.82, 1.83, 1.86 A. All poultry, poultry stuffing, stuffed meats and stuffings containing meat are not heated to 165°F or above. Actual T oF B. All pork or any foods containing pork are not heated to 150°F or above. Actual T oF C. All shell eggs or foods containing shell eggs are not heated to 145°F or above except by consumer request. Actual T oF D. All ground meat and foods containing ground meat are not heated to 158°F or above except by consumer request. Actual T oF E. Other potentially hazardous foods requiring cooking are not heated to 140°F or above. Actual T oF (Exception: rare roast beef or rare beef from solid cuts may be served at 130°F or above) F. Precooked, refrigerated, potentially hazardous foods are not reheated to 165°F or above within two hours. Actual T oF, Actual Time Hours G. Commercially processed, precooked potentially hazardous foods are not heated to 140°F or above within two hours. Actual T oF, Actual Time Hours H. Whole frozen poultry or poultry breasts, other than a single portion, are being cooked frozen or partially thawed. PART 2 – ESTABLISHMENT SANITATION, DESIGN AND MAINTENANCE 8. FOOD NOT PROTECTED IN GENERAL 14-1.40 THROUGH 1.45, 1.50, 1.80, 1.81, 1.86, 1.87, 1.88, 1.97, 1.100, 1.110, 1.180** A. Food not protected during storage, preparation, display, transportation and service, from potential sources of contamination food uncovered, mislabeled, stored on floor, missing or inadequate sneeze guards, food containers double stacked) B. In use food dispensing utensils improperly stored C. Improper use and storage of clean, sanitized equipment and utensils D. Single service items reused, improperly stored, dispensed, not used when required E. Accurate thermometers not available or used to evaluate refrigerated or heated storage temperatures F. Improper thawing procedures used G. Raw foods not properly washed prior to serving 9. POOR HYGIENE AND ACTIVITIES OF FOOD WORKERS. 14-1.71, 1.72, 1.176, 1.177 A. Inadequate personal cleanliness B. Tobacco is used: eating, drinking in food preparation, dishwashing, food storage areas C. Hair is improperly restrained. D. Dressing rooms dirty, not provided, improperly located 10. POOR SANITARY DESIGN, CONSTRUCTION, INSTALLATION OF EQUIPMENT AND UTENSILS. 14-1.90 THROUGH 1.96, 1.100, 1.101, 1.102 A. Food (ice) contact surfaces are improperly designed, constructed, installed, located (cracks, open seams, pitted surfaces, tin cans reused, uncleanable or corroded food contact surfaces) B. Non-food contact surfaces and equipment are improperly designed, constructed, installed, maintained (equipment not readily accessible for cleaning, surfaces not smooth finish) 11. IMPROPER CLEANING, WASHING AND SANITIZING OF EQUIPMENT AND UTENSILS. 14-1.110 THROUGH 1.117 A. Manual facilities inadequate, technique incorrect: mechanical facilities not operated in accordance with manufacturer's instructions B. Wiping clothes dirty, not stored properly in sanitizing solutions C. Food contact surfaces not washed, rinsed and sanitized after each use and following any time of operations when contamination may have occurred D. Non-food contact surfaces of equipment not clean 12. IMPROPER SANITARY FACILITIES AND CONTROLS. 14-1.10, 1.130, 1.140 THROUGH 1.143 A. Hot, cold running water not provided, pressure inadequate B. Improperly functioning on-site sewage disposal system, improper/unapproved municipal sewer connection C. Plumbing and sinks not properly sized, installed, maintained: equipment and floors not properly drained D. Toilet facilities inadequate, inconvenient, dirty, in disrepair, toilet paper missing, not self-closing doors, missing hand wash signs E. Handwashing facilities inaccessible, improperly located, dirty, in disrepair, improper fixtures, soap and single service towels or hand drying devices missing 13. IMPROPER GARBAGE AND RUBBISH DISPOSAL 14-1.150 A. Adequate, leakproof, non-absorbent, vermin-proof, covered containers not provided where needed. B. Garbage storage areas not properly constructed or maintained, creating a nuisance 14. INADEQUATE INSECT/RODENT CONTROL 14-1.40, 1,60, 1.160 A. Insects, rodents present. B. Effective measures not used to control entrance (rodent/insect-proof construction) Harborage areas available for rodents, insects and other vermin C. Pesticide application not supervised by a certified applicator/in accordance with label directions/in accordance with applicable laws 15. IMPROPER CONSTRUCTION AND MAINTENANCE OF PHYSICAL FACILITIES. 14-1.88,14-1.170 THROUGH 1.175,1.180,1.181,1.182.1.183 A. Floors, walls, ceilings, not smooth, properly constructed, in disrepair, dirty surfaces B. Lighting and ventilation inadequate, fixtures not shielded, dirty ventilation hoods, ductwork, filters, exhaust fans C. Premises littered, unnecessary equipment and article present, living quarters not completely separated from food service operations, live animals, birds and pets not excluded D. Improper storage of cleaning equipment, linens, laundry unacceptable 16. MISCELLANEOUS, ECONOMIC VIOLATION, CHOKING POSTER, TRAINING. 14-1.73,1.190 NUMBERS LISTED REFER TO 10 SUBPART 14-1 DOH-192 (10/05) DOH-192 (12/11)