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Retail Food Establishment Report Template

This document summarizes violations found during an inspection of a retail food establishment. It records temperature observations of food processes and locations, along with details of each violation including the item number, citation from Regulation 61-25, and required corrective actions. Failure to address the violations may result in permit suspension or downgrading of the establishment.

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51 views2 pages

Retail Food Establishment Report Template

This document summarizes violations found during an inspection of a retail food establishment. It records temperature observations of food processes and locations, along with details of each violation including the item number, citation from Regulation 61-25, and required corrective actions. Failure to address the violations may result in permit suspension or downgrading of the establishment.

Uploaded by

narasimma8313
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Retail Food Establishment Documentation Report Date

Bureau of Environmental Health Services


Division of Food Protection and Rabies Prevention / /
Establishment Name Permit #
- -

Temperature Observations
Product, Process, & Location °F Product, Process, & Location °F

Item Citation Violation P/Pf CDI CV VR


P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
E
P/Pf CDI CV VR
P/Pf CDI CV VR
PL
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
M

P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
SA

P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR
P/Pf CDI CV VR

Remarks
PIC Name PIC Signature/Initial
DHEC 1722BW (06/2014) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
SCDHEC, UST Management Division, 2600 violations
Consecutive Bull Street,may
Columbia, SC 29201,
be subject PHONE (803)898-7957
to enforcement FAX (803) 896-6245 www.scdhec.gov
action and penalty
Information collected on this form is subject to public scrutiny or release as well as the Freedom of Information Act
Retail Food Establishment Documentation Report

I. Purpose

This document is used to record items marked OUT on the Retail Food Establishment Inspection Report (DHEC 1722A).
This document is also used to record observed temperatures from a representative sampling of processes ongoing at the
establishment. Details of each violation for the item number will be documented on this report.

Failure to comply with this notice may result in suspension of your permit, or downgrading of the establishment.

II. Explanation and Definitions

Temperature Observations: Record the common name of the food as well as the process, location, and temperature of the
food at the time of monitoring, e.g. chicken, cooking, flat grill, 165 °F.

Item - The term “Item” refers to the Item number on the Retail Food Establishment Inspection Report (DHEC 1722A)

Citation - The term “Citation” refers to the section of Regulation 61-25 that corresponds with the violation items.

P/Pf = Priority P and Priority Foundation Pf - requiring immediate action


CDI = Correction During Inspection
CV = Consecutive Violation
VR = Verification Required

To obtain a copy of the SC Regulation 61-25, Retail Food Establishments, or to learn more information, please go to
www.scdhec.gov/food.

DHEC 1722B (09/2014)

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