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STATE OF FLORIDA
DEPARTMENT OF HEALTH
COUNTY HEALTH DEPARTMENT
PURPOSE:
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ROUTINE
CONSTRUCT.
COMPLAINT
QASURVEY
OTHER
FOOD SERVICE
INSPECTION REPORT
REINSPECrON
CHANGE OF OWNER
CONSLLTATIOJ\:
OTHER
RESULTS
Satisfactory
OWNER
= Incomplete
= Unsatisfactory
ZIP
PERSON IN CHARGE
BEGIN
Correct Violations by
Next Inspection
8:00AM on:
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PHONE
END
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DATE
DATE
POSITION
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CERTIFICATE
NUMBER
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TYPE
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Hospital
Nursing
Detention
Lounge
Civic
Movie
School
Residen.
Child
Limited
Other
Items marked below violate the requirements of Chapter ME-II of the Florida Administrative Code and must be corrected. Continued operation of this facility
without making these corrections is a violation of Chapter ME-II. Florida Administrative Code and Chapters 381, and 386, Florida Statutes. Violations must be
corrected by the date and time indicated in the Results section above or an administrative fine or other legal action will be initiated.
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FOOD SUPPLIES
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1. Sources, etc.
FOOD PROTECTION
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2. Stored temperature
3. No further cookinglRapid
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6. Pork cooking
= 7. Poultry
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cooling
5. Raw fruits
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cooking
8. Other animal cooking
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O. Food container
II. Buffet requirements
condiments
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Reserviceoffood
16. Poisonous/Toxic
materials
17. Exclusion of personnel
29. Cleanliness
of equipment
30. Methods of washing
FACILITIES
AND CONTROLS
19. Tobacco use
20. Handwashing
21. Handling of dishware
22. Refrigeration facilities/Thermometers
23. Sinks
24. Ice storage/Counter-protector
25. Ventilation/Storage/Sufficient
26. Dishwashing
and fabrication
28. Installation and location
SANITARY
18. Cleanliness
ITEM
NUMBERS
equipment
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3). Water supply
FACILITIES
AND OPERATIONS
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39. Other facilities and operations
TEMPORARY
SERVICE
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33. Sewage
FOOD
EVENTS
40. Temporary food service events
VENDING
32. Ice
MACHINES
41. Vending machines
MANAGER
CERTIFICATION
= 42. Manager
34. Plumbing
35. Toilet facilities
36. Handwashing
OTHER
CERTIFICATES
facilities
37. Garbage disposal
38. Vermin control
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certification
AND FEES
43. Certificates and fees
INSPECTIONIENFORCEMENT
44. InspectionlEnforcement
facilities
COMMENTS
AND INSTRUCTIONS
(continue on attached sheet)
nssun DE""MENTmsPEcm~
COPY OF REPORT RECEIVED
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offood
EQUIPMENT/UTENSILS
9. Least contactlReheating
I 2. Self-service
15. Transportation
PERSONNEL
= 4. Thawing
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= 27. Design
14. Sneeze guards
BY:
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DH Form 4023, 1/05 (Obsoletes Previous Editions)
W
ICHD/HEADQUARTERS
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