Retail Food Establishment Inspection Report
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1
2
3Texas Department of State Health Services
Retail Food Establishment Inspection Report
Date:
Time in:
Time out:
License/Permit #
Est. Type
Risk Category
Page __ of ___
Purpose of Inspection:
1-Compliance
2-Routine
3-Field Investigation
4-Visit
5-Other
TOTAL/SCORE
Number of Repeat Violations: ____
Establishment Name:
Contact/Owner Name:
Number of Violations COS: _____
Physical Address:
City/County:
Zip Code:
Phone:
Follow-up: Yes
No
(circle one)
Compliance Status:
Out = not in compliance
IN = in compliance NO = not observed NA = not applicable COS = corrected on site
R = repeat violation
Mark ‘’ a checkmark in appropriate box for IN, NO, NA, COS
Mark an asterisk ‘ ’ in appropriate box for R
Mark the appropriate points in the OUT box for each numbered item
Priority Items (3 Points)
violations Require Immediate Corrective Action not to exceed 3 days
Compliance Status
Compliance Status
O
I
N
N
C
R
O
I
N
N
C
R
Time and Temperature for Food Safety
Employee Health
U
N
O
A
O
U
N
O
A
O
(F = degrees Fahrenheit)
T
S
T
S
1. Proper cooling time and temperature
12. Management, food employees and conditional employees;
knowledge, responsibilities, and reporting
2. Proper Cold Holding temperature(41°F/ 45°F)
13. Proper use of restriction and exclusion; No discharge from
eyes, nose, and mouth
3. Proper Hot Holding temperature(135°F)
Preventing Contamination by Hands
4. Proper cooking time and temperature
14. Hands cleaned and properly washed/ Gloves used properly
5. Proper reheating procedure for hot holding (165°F in 2
15. No bare hand contact with ready to eat foods or approved
Hours)
alternate method properly followed (APPROVED Y___N___)
6. Time as a Public Health Control; procedures & records
Highly Susceptible Populations
Approved Source
16. Pasteurized foods used; prohibited food not offered
Pasteurized eggs used when required
7. Food and ice obtained from approved source; Food in
good condition, safe, and unadulterated; parasite
Chemicals
destruction
8. Food Received at proper temperature
17. Food additives; approved and properly stored; Washing Fruits
& Vegetables
Protection from Contamination
18. Toxic substances properly identified, stored and used
9. Food Separated & protected, prevented during food
Water/ Plumbing
preparation, storage, display, and tasting
10. Food contact surfaces and Returnables ; Cleaned and
19. Water from approved source; Plumbing installed; proper
Sanitized at _______ ppm/temperature
backflow device
11. Proper disposition of returned, previously served or
20. Approved Sewage/Wastewater Disposal System, proper
reconditioned
disposal
Priority Foundation Items (2 Points)
violations Require Corrective Action within 10 days
O
I
N
N
C
R
O
I
N
N
C
R
Demonstration of Knowledge/ Personnel
Food Temperature Control/ Identification
U
N
O
A
O
U
N
O
A
O
T
S
T
S
21. Person in charge present, demonstration of knowledge,
27. Proper cooling method used; Equipment Adequate to
and perform duties/ Certified Food Manager (CFM)
Maintain Product Temperature
22. Food Handler/ no unauthorized persons/ personnel
28. Proper Date Marking and disposition
Safe Water, Recordkeeping and Food Package
29. Thermometers provided, accurate, and calibrated; Chemical/
Labeling
Thermal test strips
23. Hot and Cold Water available; adequate pressure, safe
Permit Requirement, Prerequisite for Operation
24. Required records available (shellstock tags; parasite
30. Food Establishment Permit (Current & Valid)
destruction); Packaged Food labeled
Conformance with Approved Procedures
Utensils, Equipment, and Vending
25. Compliance with Variance, Specialized Process, and
31. Adequate handwashing facilities: Accessible and properly
HACCP plan; Variance obtained for specialized
supplied, used
processing methods; manufacturer instructions
Consumer Advisory
32. Food and Non-food Contact surfaces cleanable, properly
designed, constructed, and used
26. Posting of Consumer Advisories; raw or under cooked
33. Warewashing Facilities; installed, maintained, used/
foods (Disclosure/Reminder/Buffet Plate)/ Allergen Label
Service sink or curb cleaning facility provided
Core Items (1 Point)
Violations Require Corrective Action Not to Exceed 90 Days or Next Inspection , Whichever Comes First
O
I
N
N
C
R
O
I
N
N
C
R
Prevention of Food Contamination
Food Identification
U
N
O
A
O
U
N
O
A
O
T
S
T
S
34. No Evidence of Insect contamination, rodent/other
41.Original container labeling (Bulk Food)
animals
35. Personal Cleanliness/eating, drinking or tobacco use
Physical Facilities
36. Wiping Cloths; properly used and stored
42. Non-Food Contact surfaces clean
37. Environmental contamination
43. Adequate ventilation and lighting; designated areas used
38. Approved thawing method
44. Garbage and Refuse properly disposed; facilities maintained
Proper Use of Utensils
45. Physical facilities installed, maintained, and clean
39. Utensils, equipment, & linens; properly used, stored,
46. Toilet Facilities; properly constructed, supplied, and clean
dried, & handled/ In use utensils; properly used
40. Single-service & single-use articles; properly stored
47. Other Violations
and used
Received by:
Print:
Title: Person In Charge/ Owner
(signature)
Inspected by:
Print:
Business Email:
(signature)
Form EH-06 (Revised 09-2015)
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