Montgomery County Health Department Page 1 of 1-11191 Illinois Route 185

Hillsboro IL 62049 Division of Environmental Health

(217) 532-2001

FOOD ESTABL1SHMENT INSPECTION REPORT I

turposa 'of Inspection (circle one __ _~ , \

( Routin'8\ Follow-up Pre-opening Complaint Educational Other rlJ'jU dUKNt: ILL,Nt:::;::; KI::;K rAt.; I UK::;'ANU PUBliC HEALl!:i IN 1 tRVtN liON::;

Circle designated compliance slalus (IN, OUT, N/O, N/A) for each numbered ilem

IN=in compliance OUT=out of compliance N/O=nol o~served N/A=not applicable

Compliance Status C R

1 [J.tO:lUT

2 iI..lN) OUT NIA

3 ~OUT 4 ~ OUT 5 ItJ)OUT

6 [INJ OUT

7 0 1t-DOUT

8 (fN ):lUT

9 '1!:!l 0UT NIA

10 IN ~UT

Demonstration of KnowleQge '

Person in charge present, demonstrates knowledge and duties

Certified Food Protection Manager Requirement Compliance

Employee Health

Management, food employee and condilional employee; knowledge, responsibilities and reporting

Proper use of re striction and exclusion

ProceedUf!=lS for responding to vomiting and diarrheal events

, Good Hygienic Practices

I~O IProper eating, tasting, drinking, tobacco use

NO No discharge from eyes, nose, and mouth

Preventing Contamination by Hands

NO Hands clean, handwashing procedures

NO No bare hand contacl with RTE foods or allernative procedure

Adequate handwashing facilities supplied & accessible

Approvt?d Source

11 IN'P UT Food oblained from approved source

12 Illl OUT NIA ~O ood received at ploper tempera lure

13 IN)::JUT ~ood in good condi lion, safe, unadulter"ted

14 IN OUT ~1fi::J NO Required records available; shellstock tags, parasite destruciion

II Risk factors are imporlant practices or procedures identified as Ihe most prevalent

I I

'- ,;-

contnbuting faclors of food borne illness and injury, PubliC Health Intervenlions are control ~easures to pr~vent foodbome illness or injury, Risk factors re~uire immediate correction ,

Mark "X" in appropriale box for C and/or R

C=correcled on-site during inspection R=repeat violalion (2X demerits)

Compliance Status

;..,.' - - Protection from Contamination

11 IIJ\!' OUT NIA NO Food separaled & protected

1 El III!J OUT NIA Food coniacl surfaces clean & sanitized

~I Proper disposition of returned, previously served, reconditioned & HV UT unsafe food

.A. ,- Poientiilily H~zardous Food TimelTemperature

1 ~ Itj) OUT NIA NO Proper cooking tim~ & temperalure

'19 IN OUT N/A f!l: Proper rehealing procedures for hoi holding

20 IN OUT NIA ( ~ Proper cooling time '& temperature

21 .!!i OUT NIA(l'J'l; Proper 1101 holding temperalure

22 lli)OUT N/A NO Proper cold holding temperature

2~ It:Oo UT NIA NO Proper date marlling & disposilion of PHF

24 IN OUT(NI~ NO Time as a public heallh conlrol: approved procedure & records

" Consumer Advisory

25 IN OUT( NIJ¥ Consumer advisory provided for raw or undercooked foods

.. Hig/lly Susceptible Populations

21'fD!:D OUT NIA Proper foods used for susceplible populalions , -

Chemical

27 IN OUT (NI~ NO Food additives: approved and properly used

i~ Itj) OUT NIA Toxic items properly identified, stored & used

__ Approved Procedures

29 IN OUT{ NIAJ Compliance with variance, HACCP, special processes

Mark "X" in appropriate box for C and/or R

Ie R

Good Retail Practices are prevenlable measures (0 conlrol addition of pathogens, chemicals, and physical objects into food,

Mark "X" in box if numbered item IS NOT in compliance C=corrected on-site during inspection R=repeat violation C R C R

Safe Food and Water Proper Use of Utensils

30 Pasteurized eggs used where required 43 In-use utensils; properly stored

31 Water and ice from approved source 44 Utensils, equipment & linens; properly stored, washed, dried & handled

32 Variance obtained for specia lized processing rnethods 45 Single-service articles: properly stored & used

Fgoo Temperature Control 46 Gloves used properly

33 Proper cooling methods; adequate equipment for temperature control Utensils, Equipment and Vending

34 Plant food properly cooked for hot holding 47 Food and Non-food contact surfaces: constructed, installed, maintained

35 Approved thawing methods 48 Warewashing facilities: installed, maintained & used; test strips

36 Thermometerslguages provided, used & accurate 49 Non-food contact surfaces clean

Food Identification Physical Facilities

37 Food properly labeled; original container 50 Hot & cold water available, adequate pressure

Prevention from Contamination 51 Plumbing installed; proper backfiow devices

38 Insects/rodents/animals not present; unauthorized persons; openings 52 Sewage & wastewater properly disposed

39 Contamination prevented during food preparation, storage & display 53 Toilet facilities constructed, supplied & cleaned, self-closing doors

40 Personal cleanliness (presentation) 54 Garbage & refuse properly disposed; facilities maintained

41 Wiping cloths: properly used & stored 55 Physical facilities properly installed, maintained & clean

42 Fruits & vegetables properly washed before use 56 Adequate ventilation & lighting; deSignated areas used

Employee Training

@ NO (circle one) Compliant with ihe Smoke-Free Illinois Act? All food employees have food handler training within 30 days of hire

Documentation of Allergen Awareness Training

Updated 1/2019

Montgomery County Health Department Page 20f ~

11191 Illinois Route 185 Hillsboro IL 62049

Division of Environmental Health (217) 532-2001

, FOOD ESTABLISHMENT INSPECTION REPORT

I

Estabtishment M/""}~\('('\~" r-\, \\"\(' ~\ rY\ t ~t) \.n.."-' r ermit# '19.. 4 L.9- Date \ I \ 1 I \ q '-..J ----. WAJ:ER AND WASTEWATER OS::iI=RVATIONS

(Pubii0 Water suppty (circle one) Private (publiC) Wastewater Supply (cirle one) Private

I t:MI-'t:KA I UKt: OBSERVAT!ONS SANITIZER Ut:S::>t:KVA IIUN::> Concentrationl

Item/Location Temperature Item/Location Temperature Sanitizer Temperature

~\Lln- _ \{)oF \~~~ ~ \(A,,\l < TI of O\~ '1.00 A OF

\()\ ,~~ of \ I An I \ r-t .:J.\ OF ('~ \(\r, I'\.Q \CX~ A OF

6t?\~ ~\ of l-J of ppm I of

of of ppm/oF

of of ppm I of

--- _ CERTIFieD r~~[J t-'KU I t:L;lIQ~ , IV!~Nf\G_E:!;{ ' CtR III-'1qb:.rIONR~l}l.B.E~Mc~Nl .-Manager Name Certification Number Expiration Date Present During Inspection? Original Copy Posted in Facility?

""" t--.. .\~. YES NO YES NO ~'"",,.. \ ..... (! r-.. ,,.... --.:

YES NO YES NO

( ... a...-t~u ~r\jrr- .... _0..+ 7YE~ NO (YEm NO I _HAC~P TOPIC;:

. \5\s.c\.)~')(-.n1\-~ \~ r\C{ ~ D~ ~-rf\nQf ~~~\I~ ~~\e . - -~ - -< ._.- .~. .' --

. ITEM OBSE~'{ATrotJSY>tND ~RRRE~TIVEACTIONS Correct By

Item # Explanation of Violation and Recommendations for Correction (NRI = Next Routine Inspection)

Received by (Signatt' 11:it. & ,-r--- Received by (printed) Title /l M '1/.11.. ~ --Inspecto'ign~~f"'\. &. ~ . Follow-up required? YES N01 (circie one) Follow-up date:

1\ \ rv-J\

0

Updated 1/2019