FOOD SAFETY INSPECTION REPORT AUDITOR: DATE: SCORE MANAGER: UNIT #:

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1 CONCEPT: STREET ADDRESS: FOOD SAFETY INSPECTION REPORT AUDITOR: DATE: SCORE MANAGER: UNIT #: TIME IN: TIME OUT: in = in compliance; out = out of compliance; no = not observed SECTION I - Risk Factors POINT VALUE - 5 POINTS FOR EACH OPPORTUNITY * CONTACT SUPERVISOR IMMEDIATELY POTENTIALLY HAZARDOUS FOOD 6* in out no Employee health 1.1 in out no Cold holding of PHF ºF. Multiple Systems breakdown O Unprotected coughing or sneezing holding PHF in the Danger Zone. O No discharge from eyes, nose, mouth O Proper cold holding temperatures O Employee with a reportable disease (Big 7) 1.2 in out no Hot Holding of PHF ºF. Multiple Systems breakdown 7 in out no Hands clean and properly washed holding PHF in the Danger Zone. O Not washing hands as needed O Proper hot holding temperatures O No double hand wash after using the restroom 2 in out no Improper cooking O No supplies available in entire restaurant O Cook for immediate service O No hand wash between glove changes O Cook for hold O Handling raw food then ready to eat food without O Par cooking observed hand wash and glove change VERMIN 3 in out no Improper reheating 8* in out no Rodents/ Cockroaches - active O 165 for 15 seconds, rapidly within 2 hours O Mice o r rats O Roaches O Reheating 9 in out no Flies - immediate risk WATER and SANITIZING 4 in out no Improper cooling 10 in out no Sanitizing - dishmachine/ dishsink O Deep container O Chemical sanitizer not available in restaurant O Covered container O No ice bath 11* in out no No water/ no hot water at 2 or more sinks O Not stirred SEWAGE 12* in out no Sewage backup - (includes toilets, drains, sinks,etc) PREVENTING CONTAMINATION O Dishroom O Restroom 5 in out no Adultered food/ approved source O Line O Approved source 13* in out no Toilets - no operable toilets SECTION II - Risk Factors POINT VALUE - 3 POINTS FOR EACH OPPORTUNITY POTENTIALLY HAZARDOUS FOOD GOOD HYGIENIC PRACTICES 14.1 in out no Cold Holding of PHF 43-59ºF 22.1 in out no Employee practices O Cold holding O Drink/ food in designated place 14.2 in out no Hot Holding of PHF ºF O Proper eating, tasting, drinking, or tobacco use O Hot holding 22.2 in out no Improper glove use O No barehand contact with RTE food 14.3 in out no Time as a control O Double gloving observed O Time as a control not followed O Improper glove use 15 in out no Diligent preparation O Improper use of Sher Mitt O 20 minutes prep time O Observed 1 Sher Mitt use O 20 min. at room temp for pizookie dough O Observed 2 Sher Mitt uses O Too much food being prepped O Observed 3 Sher Mitt uses O Food not being attended to in timely manner O Observed >3 Sher Mitt uses 16.1 in out no Improper Thawing 22.3 in out no Improper handwashing (medium) 16.2 in out no Improper thawing of Mahi and Ahi Tuna O Improper handwash O Mahi Mahi or Ahi Tuna thawed in cryovac packaging O Paper towel use to turn off hand sink faucet PROTECTION FROM CONTAMINATION PROTECTION FROM CONTAMINATION 17.1 in out no Food Protected (covering and elevating) 23.1 in out no Food contact surfaces - equipment O Not covered in storage ( 2 or more) O Can opener O Scale 17.2 in out no Food Protected (labeling) O Dicer O Slicer O Open PHF expired O Mixer O PHF held >24 hours not date marked ( 2 or more) O Not labeled non descript ( 2 or more) Page 1 of 5

2 18 in out no Contamination risk 23.2 in out no Food contact surfaces - small wares and utensils O Washing fruits and vegetables O Knife O Three sets of silverware unclean O Using a cutting board on a trash can O Cutting board O Utensils or wares in storage O Food prepared in unapproved area O Food container O Scoop buried in food O Mixing bowls O Prep sink not washed between uses O Bar glasses unclean 23.3 in out no Food contact surfaces - Ice Machine / Ice Bins / Miscellaneous 19 in out no Food Separated O Cutting gloves O Soda nozzle O Raw over ready-to-eat (RTE) O Ice bin O Tea nozzle O Raw poultry over other raw foods O Ice maker O Utensil holder O Cutting boards not changed per policy O Knife holder O Oven mitt(s) O Fan guards (w/uncovered RTE food) 20 in out no Handsinks not stocked 24 in out no Sanitizing - dishmachine/ dishsink O No soap Only deduct if this is during active sanitizing O No towels O ppm too low O water temp too low O No waste receptacle at rest room handsink area O ppm too high O water temp too high CHEMICAL 25 in out no Plumbing installed; proper backflow devices 21 in out no Hazardous Chemicals - Storage/Use - High Risk O Water and ice from approved source O Properly stored 26.1 in out no Critical sink fixture - no hot water at 2 sinks O Properly used O No water at 2 hand sinks 26.2 in out no Critical sink fixture - no hot water at 2 sinks O Handsink inaccessible or blocked O Sink inoperable or misused SECTION III - Good Retail Practices POINT VALUE - 1 POINT FOR EACH OPPORTUNITY FOOD 36 in out no No hot water - no immediate risk (1 sink) 27.1 in out no Spoilage/ mold on produce O Dish / hand / prep sink O Moldy or spoiled product 37 in out no Hood - not clean/ disrepair/ missing/ gap O Expired product O Gap between filters O Missing filter 27.2 in out no Pure food/ dented cans O Hood filters placed sideways O Unclean filter O Can - bad rim O No spoils area O Gas equipment no under hood O Can - dented O Equipment giving off steam / smoke is not under hood O Can - swollen 38 in out no Poor lighting 27.3 in out no Raw Steak Storage O Missing or broken light shield endcap DO NOT deduct if steaks have fallen over in pan on line. O Missing endcap Only deduct if they stored the steaks horizontal on purpose 39 in out no Ventilation - unclean ceiling vent O Improper steak storage on cooks line 40 in out no Condition - disrepair O Steaks on cooks line in vacuum packaging O Fry basket O Knives O Steak improperly stored horizontally in container on O Cutting boards O Utensils cooks line. O Wares O Gaskets 28 in out no Improper inspection at delivery/ transportation O Equipment O Shelves OPERATIONS O Oven mitt : 29 in out no Dispensers -soap/ towel broken, but supplies available O Shaker basket O Soda machine drip pan (rusty) O Towels on dispenser but not in dispenser PROPER USE AND STORAGE O Dispenser broken 41.1 in out no Storage (non food) O Utensil water O Dipper well off 30 in out no Employee hygiene & cleanliness O Wedged utensils O FIFO O Missing hair restraints (hairnet or hat) O Labels not facing forward O Pans wet nested w/o residue O Soiled apron/ uniforms O Inverted single-use items O Scoop handle touching food O Fake or painted nails/ jewelry on hands and arms O 18 inches from fire sprinkler O Employee chewing gum O Bread tie on package at cooks line O Jewelry on hands and arms while doing food prep O 12 inches from floor for metro racks 31 in out no Hazardous materials/ chemicals - low risk 41.2 in out no Gluten Free Procedures 32 in out no Interior premises -storage of linen/ castoff O Did not use a separate "gluten free batch" of product in out no Non food contact surfaces - prep kitchen O Gluten free pans not separated. O Counters O Shelves O Gluten free procedures (gluten stored with non-gluten) O Hood O Stove knobs O Gluten free stored below gluten containing food. O Hood filters O Gluten free utensils not washed and sanitized every two hours. O Oven O No glove change before a new Gluten free order. O Oven knobs O Utensils not stored separated and protected/covered. Page 2 of 5

3 33.2 Non food contact surfaces - kitchen 42 Unapproved type/ improper use/ improper installation O Counters O Grill O Tape on utensils O Crates used as shelf O Cords O Handle O Foil lining equipment O Crates used to store items O Fan Guards O Hood O Cardboard on floor O Food in plastic grocery bags O Fryer Cabinet O Hood filter O Missing drain plug at sink O Scoop w/o handle O Microwave O Shelves O Wet cloth under cutting board O Pizza oven O Under grill O Absorbent material lining shelves O Refrigerator 43 Wiping cloth : properly used and stored 33.3 Non food contact surfaces - server alley / beverage stations O Wet wiping cloth not stored in sanitizer O Fan Guards O Soda gun holder O Wiping cloth solution is turbid O Handle O Soda machine drip pan O Sanitized bucket not labeled O Separate cloth used for raw food O Ice cream well O Soda nozzles 44 Sanitizer buckets - improper concentration/ test kit Only use facility's QT40 strips to test O Refrigerator O QUAT / CL too high O No test strips available O Shelves O QUAT / CL too low O Wrong strips in use 33.4 Non food contact surfaces - bar O QUAT dispenser at improper level O Bar mats O Refrigerator 45 Thermometers provided and accurate O Bar wrapping O Soda machine drip pan O No thermometer O Improper use O Cabinets O Soda gun holder O Not conspicuous/ visible O Not NSF approved O Counters O Not accurate O Handle WALLS/ CEILINGS/ FLOORS 33.5 Non food contact surfaces - walk in coolers and dish area 46 Deterioration/ unapproved materials O Dishmachine O Shelves 47 Unclean floors, walls, ceiling O Ice build up O Floors O Walls O Rolling racks O Standing water (floor) O Ceiling 33.6 Non food contact surfaces - gaskets VERMIN O Alto Shaam O Reach in - stand up 48 Rodents/ cockroaches - no active population O Line Drawers O Reach in - cold top 49 Other insects (i.e. fruit & drain flies) - low risk O Oven O Walk in freezer 50 Open door/ air curtain/ window O Walk in cooler TOILETS/ TOILET ROOMS/ DRESSING ROOMS PHYSICAL FACILITY 51 Toilet(s)-disrepair/ not clean/ tissue in dispenser 34 Sink/ floor sink/ floor drain 52 Toilet room doors not self-closing O Not clean 53 Personal items / Dressing room O Clogged/ slow draining REFUSE/ PREMISES/ JANITORIAL 35 Supply line/ waste line 54 Janitorial - supplies/ equipment/ tools in improper place O No air gap 55 Refuse containers/ exterior premises O Leaking O Trash receptacle O Grease receptacle O Not secure, poor installation O Exterior premises/ loading dock SECTION IV - Administrative NO POINTS SUBTRACTED FROM OVERALL SCORE FOR THIS SECTION Logs (1 point Each) SIGNS/ PERMITS 56A Dish and Temperature Log 56C Flawless Execution Logs 56 Health inspection/ permit not available for review O Complete O Complete 57 Certification (Food safety manager) O >90% complete O >90% complete 58 Food handler card (where applicable) O <90% complete O <90% complete 59 Posters: O Sher mitt poster in Kitchen 56B Station Logs 56D Time and Temperature 56E Equipment and Utensil O Handwash O Be Aware and Care O Complete records at Expo Line Checklist O Produce washing O Tell Us How You Are Feeling O >90% complete O Complete O Complete O Day Dot instructions O Personal Hygiene O <90% complete O >90% complete O >90% complete O CA only - Prop 65 signage posted O <90% complete O <90% complete 63 Master cleaning schedule posted SECTION VI - Other Risk Management Brand Quality Checks 66 Cutting glove in use (when applicable) O 15 min chicken timer 67 Wet floor sign available/ covering wet area O 30 min tortilla chip timer 68 Employees wearing slip resistant shoes [ OF ] O 20 min dinner roll timer 69 Biohazard Response Spill Kit O 2 hour soup/ baked potato timer 70 First aid kit O 60 min sanitizer bucket timer 71 Other: SECTION VII - Training & Systems POINT VALUE - 0 POINTS FOR EACH OPPORTUNITY A. Sanitizing Wash N Walk E Reportables (Big 7) O Connected and product is available. ONLY ASK THE BIG 7 DURING THE FIRST AUDIT OF THE FIRST MONTH EVERY QTR O Connected to the dispenser, but it is empty. O Knew all 7 reportable diseases. O Not connected to the dispenser, but there is product available O Auditor provided training on the Big & reportable diseases in the restaurant. F PIC Verification O There is no product at all in the restaurant. G Dispute - discussed with PIC B Handwashing H Cutting gloves available C Squeeze Bottles O How many Red gloves (8) O Squeeze bottles must be labeled to id the product inside. O How many Metal gloves (2) D FIFO I Sanitizer Bucket O Restaurants must use the First In First Out method to ensure O On the floor - proper rotation. O Off of the floor Page 3 of 5

4 NAME: ADDRESS: DATE: SECTION V - Health Inspection AUDITOR WILL CAPTURE ANY OPPORTUNITY DEDUCTED AS A CRITICAL FROM THE HEALTH AUTHORITY AT EVERY INSPECTION DATE: O Holding temperatures O Cross contamination O Thawing SCORE: O Unstocked handsink O Food not labeled O Cooking State: O Handsink blocked O Food not elevated : Jur: O Improper handwash O Unclean equipment TEMPERATURE CONTROL Food type (PHFs) Temp. Violation Equipment Location Water Control Temp/PPM Violation Location Chemical Y N Sanitizer bucket Y N Y N Dishmachine Y N Y N Dishsink Y N Y N Handsink - food area Y N Y N Handsink - restroom Y N Y N Prep sink Y N Y N Bar sink/ machine Y N Section I Opportunities - Call Everclean office if 6, 8, are observed Violation # Section II Opportunities - Indicate repeat violations 877-5ECLEAN Page 4 of 5

5 NAME: ADDRESS: DATE: FOOD SAFETY AND SECURITY REPORT Section III Opportunities Violation # Section IV, VI & Additional Comments 57 Food Safety Certificates: OF managers 61 Pest traps secured: 62 Last Pest Report Date: Comments: 63 Master Cleaning schedule: 64 SDS: I understand the recommendations that are being made to me today and agree to follow through on the corrective actions and/or training that needs to occur in order for my location to receive an "A" rating. I have agreed to do these within a timely manner. AUDITOR: DATE: 877-5ECLEAN Page 5 of 5