PliRPO

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STATE OF FLOKIUA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

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= = = =

Q-\ SURVEY OTHER

= REINSPECTION = CHANGE OF OW"ER = CONSULTATION = OTHER

fOOD SERVICE INSPECTION REPORT

ADDRESS~~~~~~~~~~~~~~~
OWNER ,PERSON IN CHARGE

__

Incomplete Unsatisfactory Correct Violations by ~ Next Inspection

= 8:00AM

on:

05 Nursing Detention Lounge c6:J12SI Cl:JJ3Q Civic 06 07 08 09 10 11 12 13

= Movie
~School

c8:Jl3&
dbl40t ct::Q1$ d:tH5() ct2J~

= Child

Residen. Limited

c::J Other

= I Sources,
~

FOOD SUPPLIES
etc.

FOOD PROTECTION

= 16. Poisonous/Toxic
cooling

=

= 14. Sneeze guards
15. Transportation of food materials

= = = = = = =

= 3. No further
4.

2. Stored temperature cooking/Rapid

Thawing

5. Raw fruits 6. Pork cooking 7. Poultry cooking 8. Other animal cooking 9. Least contact/Reheating 10. Food container Buffet requirements condiments of food

= 18. Cleanliness = 19. Tobacco use = 20. Handwashing = 21. Handling of dishware
EQUJPMENTIUTENSILS

=

PERSONNEL
17. Exclusion of personnel

= 27. Design and fabrication = 28. Installation and location = 29. Cleanliness of equipment = 30. Methods of washing
SANITARY FACILITIES AND CONTROLS

OTHER FACILITIES AND OPERATIONS
c::J 39. Other facilities and operations

TEMPORARY

FOOD

SERVICE EVENTS
c::J 40. Temporary food service events

=II.

c::J 12. Self-service

=13. Reservice
ITEM NUMBERS

= =

= 22. Refrigeration facilities/Thermometers = 23. Sinks = 24. Ice storage/Counter-protector
25. Ventilation/Storage/Sufficient 26. Dishwashing facilities equipment

= = 32. Ice = 33. Sewage = 34. Plumbing = 35. Toilet facilities = 36. Handwashing facilities = 37. Garbage disposal = 38. Vermin control
31. Water supply

=

VENDING MACHINES
41. Vending machines

MANAGER CERTIFICATION
c::J 42. Manager certification

CERTIFICATES

AND FEES

c::J 43. Certificates and fees

INSPECTIONIENFORCEMENT
c::J 44. InspectionlEnforcement

COMMENTS AND INSTRUCTIONS
(continue on attached sheet)

DH Form 4023, 1/05 (Obsoletes Previous Editions)

ESTABLISHMENT/FACILITY

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ROUTfNE CONSTRUCT

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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
REINSPECTION CHANGE OF OWNER CONSULTATION

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FOOD SERVICE INSPECTION REPORT

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8:00AM on:

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cZJl3Q

Civic Movie School Residcn.

1::8:::Jl351 c9J1IlQ d::Ollil51 d:::1J1SQ

1. Sources. etc.

=
c:::J

IS. Transportation 16. Poisonous/Toxic

of food materials

FOOD PROTECTION

= 3. No further = 4. Thawing

_

2. Stored temperature cooking/Rapid cooling

S. Raw fruits
6. Pork cooking

8. Other animal cooking 9. Least contact/Reheating
10.

Food container

II Buffet requirements 12. Self-service I 3. Reservice
0f

condiments food

= = = = = = = = =
d

PERSONNEL
17. Exclusion of personnel 18. Cleanliness 19. Tobacco use 20. Handwashing 21. Handling of dishwa!e

= = = = = = = = = =
_ equipment

28. Installation and location 29. Cleanliness of equipment 30. Methods of washing

AND OPERATIONS
~ 39. Other facilities and operations

TEMPORARY

FOOD

SANITARY FACILITIES AND CONTROLS
31. Water supply 32. Ice 33. Sewage 34. Plumbing 3S. Toilet facilities 36. Handwashing facilities

EQUIPMENTfUTENSILS
22. Refrigeration 23 Sinks 24. Ice storage/Counter-protector 25. Ventilation/Storage/Sufficient 26. Dishwashing facilities facilities/Thermometers

37. Garbage disposal 38. Vennin control

= = = = =

SERVICE EVENTS
40. Temporary food service events

VENDING MACHINES
41. Vending machines

MANAGER CERTIFICATION
42. Manager certification

CERTIFICATES
43. Certificates

AND FEES
and fees

INSPECTION/ENFORCEMENT
44. InspectionlEnforcement

ITEM NUMBERS

COMMENTS AND INSTRUCTIONS
(continue on attached sheet)

HEALTH DEPARTMENT INSPECTOR COPY OF REPORT RECEIVED B r +-----,-"~=:-=_:::h~LL=-..=::._-"'--'-_;:...,::=--.w:::::.----==----DH Form 4023, 1/05

(Obsoletes Previous Edlti07(

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PURPOSE:
_

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ROUTINE

CONSTRUCT. =COMPLA.INT';')

=

QA SURVEY

= = "'6":;c6NSuLTAiiok~: <_,; =
RElNSPECTION CHANGE OF OWNER OTIiER

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE INSPECflbNREPORT '. _,::.- :;0
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PURPOSE:
ROUTINE CONSTRUCT, CJ REINSPECTION CJ CHANGEOFO~ CJ CONSULTATION CJ OTIlER

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE, INSPECTION REPORT

=

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, Satisfactory Incomplete Unsatisfactory Correct Violations by !!!I!I Next Inspection CJ 8:00 AM on:

= COMPLAINT = QASURVEY

2012 JAN 2Y

PrJ 7 36

CJ Residen. CJ Child

=
= 27.Design
of food materials

Limited

CJ Other

= I. Sources;

FOOD SUPPLIES
etc.

CJ

14.Sneeze

guards

and fabrication and location of equipment

CJ 15. Transportation CJ 16. PoisonousIToxic

CJ 28. Installation

FOOD PROTECTION

=

29. Cleanliness

=

OTHER FACILITIES AND OPERATIONS
39. Other facilities and operations

= =
= =

rlIIIt 2. Stored temperature 3. No further cooking/Rapid 4. Thawing fruits cooking cooking cooling

PERSONNEL
CJ 17. Exclusion of personnel CJ

CJ 30. Methods of washing

= 6. Pork

= 5. Raw

= =
~

18. Cleanliness 19. Tobacco use

=

SANITARY FACILITIES AND CONTROLS
31. Water supply

TEMPORARY FOOD SERVICE EVENTS
CJ 40. Temporary food service events

VENDING MACHINES
CJ 41. Vending machines

= 7. Poultry

CJ 20. Handwashing CJ 21. Handling of dish ware

CJ 32. Ice

= 33. Sewage

8. Other animal cooking 9. Least contactIRebeating

EQUIPMENTfUTENSILS ~ 22. Refrigeration facilitieslThermometers
23. Sinks CJ 24. Ice storage/Counter-protector

CJ

=II. Buffet requirements =12. Self-service condiments

CJ 10. Food container

=

= 25. VentilationlStoragelSufficient
26. Dishwashing facilities

= 35. = =

MANAGER CERTIFICATION
CJ 42. Manager certification

34. Plumbing Toilet facilities facilities

CERTIFICATES
CJ 43. Certificates

AND and fees

FEES

36. Handwashing

equipment

= 38. Vermin control

37. Garbage disposal

INSPECTIONIENFORCEMENT
CJ 44. InspectionlEnforcement

13. Reservice

of food

ITEM NUMBERS

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FOODS

"CE VI·
EASTERN BU51NESf, 386-758-4273

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PURPOSE:
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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE INSPECTION REPORT

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lnsinllauon

FACILITIES

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SERVICE VENDING

EVENTS MACHINES CERTIFICATION AND FEES

AND CONTROLS

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INSPECTION/ENFORCEMENT
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44. Inspection/Enforcement

[);si!\-', ashing

Iaciliues

._-(continue on attached sheet)

ITEM NUMBERS

COMMENTS

AND INSTRUCTIONS

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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

=

RuL'TINE CO,",STRJ)CY.

= COMPl.-\INT = QASLRV[Y

= REINSI'HllUN = ClL-\NGE OF OIlNfR = CO'lSL'LTATION
o
OTHER

FOOD SER\ICE I:\SPECTION REPORT

=

OTHER

OWNER PERSON IN CHARGE
-v--"""C.."=<-L.-_-=-!:....<.L.....-'-=:....__~_

U"satisfactory Correct Violations by Next Inspection

= = 8:00AM

on:

Nursing Detention
c:5Jt2Q

Lounge Civic Movie Residen. Child Limited Other

c6J~ c!:Jt3Q c1!::113!!1 db HID t1tlllll$ t1:tJ t!Sl) rt2I t5!II

'rfJMi6ricfd 7i!:iihiniStrd'tlfi'tiiiJ2
~rfI1iJd"ltal,ti1i{Sird'til!i!

= = = = = = = = = = = =

FOOD SUPPLIES
I Sources. etc.

FOOD

PROTECTION
cooling

2. Stored temperature 3. No further cooking/Rapid 4. Thawing 5. Raw fruits 6. Pork cooking 7. Poultry cooking 8. Other animal cooking 9. Least contact/Reheating 10. Food container II. Buffet requirements 12. Self-service condiments

= = = = = = = =
=

~qrjm ddministrative fine oriY{tyil

Cc~~w?iI

14. Sneeze guards 15. Transportation 16. Poisonous/Toxic of food materials

= 27. Design and fabrication

PERSONNEL
17. Exclusion of person';;el 18. Cleanliness 19. Tobacco use
20.

= = =

.'"

OTHER

FACILITIES

28 Installation and location
29. Cleanliness of equipment

= = = =

AND OPERATIONS
39. Other facilities and operations

30. Methods of washing

TEMPORARY SERVICE VENDING

FOOD

SANITARY FACILITIES

EVENTS MACHINES CERTIFICATION
certification

Handwashing

21. Handling of dish ware

EQUIPMENT/UTENSILS
22. Refrigeration

.= 23. Sinks

facilitie&fThermomet~rs

I

= = = = =
=

AND CONTROLS 31. Water supply
32. Ice 33. Sewage

40. Temporary food service events
41. Vending machines

= 34. Plumbing
facilities facilities 36. Handwashing 37. Garbage disposal 38. Vermin control

= 42. Manager

MANAGER

='15 Toilet .'

CERTIFICATES

AND FEES

=13.

Reservice of food

= 26. Dishwashing

=

= 24. Ice storage/Counter-protector
25. Ventilation/Storage/Sufficient facilities equipment

43 Certificates and fees

= 44. Inspection/Enforcement

INSPECTIONIENFORCEMENT

COMMENTS

(continue on attached sheet)

AND INSTRUCTIONS

HEALTH DEPARTMENT INSPE~ COPY OF REPORT RECEIVED BY
DH Form 4023, ~/05

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STATE OF fLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
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PUBUCI PRJVJ\TE SCHOOL INSPECTION REPORT

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,iflhe Fioi-iJd ,<;Iaiu;c.s' (fS)~ lhi.<iorm ;'/11 s.:n·c "s C1 ""'QIi(:~ tJ( ,,;;'--:-C;mpk.Jl7cc; I;;' al7"";07alio;U~oti!d iiemf ",ai*~d bt!lo;''-v~7QI~ Ih~ - - . ofChaptt!,.l (j,J£-13 ..nd (,4r;-; / (!( tile Florlda Aomini.str(Jtil'C' Code (Fltc) and must be corrected ..·ithin the um« period ;ndic-aled in rhe "ReJ:IIILf" ,fcc-lion .. bove. ('OfflII1JJI!O op""()JiQI'I of lhi! jiJeillf) , wltbou: mllkillg 111('.;( corn:clion~ is U violation 0/ Chopter 64E-13 and ME-JJ, F4C, and Chapter 381. FS . F't:ltlthl' 10 t:q,.~t:( vl%tiolU m~' ""wit It! lJJ'I administrotlve f/JIc Of' ()Ih<:r'''-gal u,riqn hfm~ il7iti"'cd 0' conliml(:d, SCHOOLSA]\IfTATION
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PURPOSE:
ROUTINE

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

= CONSTRUCT = COMPLAINT = QASURVEY

= = = =

REINSPECTlON CHANGE OF OWNER CONSULTATION OTHER

FOOD SERVICE INSPECTION REPORT

Satisfactory Incomplete Unsatisfactory

Nursing Detention Lounge Civic Movie School Residcn. Child Limited

= = = = =
2. Stored temperature 3. No further cookingfRapid 4. Thawing 5. Raw fruits 6. Pork cooking 7. Poultry cooking 8. Other animal cooking 9. Least contactfReheating cooling

14. Sneeze guards I 5. Transportation 16. Poisonousffoxic of food materials

= =
= = =22.

=

PERSONNEL
17. Exclusion of personnel 18. Cleanliness 19. Tobacco use 20. Handwashing 21.Handlingofdishware

= = = =
=

OTHER FACILITIES
28. Installation and location 29. Cleanliness of equipment 30. Methods of washing

=

AND OPERATIONS
39. Other facilities and operations

TEMPORARY

FOOD
food service events

SANITARY FACILITIES

EQUIPMENT/UTENSILS

II. Buffet requirements 12. Self-service condiments

= = =
=

Refrigeration 23. Sinks

facilities/Thermometers

= = = = =
= ~

AND CONTROLS
31. Water supply 32. Ice 33.Sewage 34. Plumbing 35. Toilet facilities 36. Handwashing facilities

=
= =

SERVICE EVENTS
40. Temporary

VENDING MACHINES
41. Vending machines

MANAGERCERTIFICATlON
42. Manager certification

CERTIFICATES
= 43. Certificates

AND FEES
and fees

24. Ice sto~e!<funter-protector '25. VentilationiStorage!Sufficient 26. Dishwashing facilities equipment

37. Garbage disposal 38. Vermin control

INSPECTION/ENFORCEMENT
= 44. Inspection/Enforcement

13. Reservice of food

ITEM NUMBERS

,COMMENTS
..

(continue on attached sheet)

AND INSTRUCTIONS

HEALTH DEPARTMENT

INSPECTOR: BY.

~bQtlJk~
Editions) .

COPY OF REPORT RECEIVED
DH Form 4023, l/OS (Obsoletes

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Previous

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PHONE. DATE. __
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ESTABLISHMENT/FACILITY

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY PUBLIC HEALTH UNIT
Date-

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Identification

No_

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Comments and Instructions (Continued from Page I):

Copy of Report Received by Page 2
DR 4104, 4/96

(Stock Number: 5744-000-4104-8)

RECEIPT OF REPORT

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URPOSE:
ROUTINE CONSTRUCT. c:::J COMPLAINT c:::J QA SURVEY

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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE INSPECTION REP<m~ ~-

~

o~
,

c::J RElNSPECTlON c::J CHANGE OF OWNER c::J CONSULTATION c::J OTHER

U

Satisfactory Incomplete Unsatisfactory Correct Violati1m~. y ~ ct!JtNext IDsp~
Cl

8:00 AM

oti:

FOOD SUPPLIES
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c::J 27.
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fabrication

1. Sources, etc.

28. Installation and location of equipment

OTHER FACILITIES AND OPERATIONS
~39. Other facilities and operations

FOOD PROTECTION
c;:J c;:J

c::J 29. Cleanliness

2. Stored temperature 3. No further cooking/Rapid 4. Thawing cooling

PERSONNEL
c;:J

E!!!!Jt 30. Methods of~ashing
of personnel

=

17. Exclusion

c:::l 18. Cleanliness c:::l 19. Tobacco use c::J 20. Handwashing c::J 21. Handling of dishware

c:::l 5. Raw fruits c:::l 6. Pork cooking

=
facilities/Thermometers

SANITARY FACILIThtS AND CONTROLS
31. Water supply

TEMPORARY FQOD SERVICE EVENTS
c:::l 40. Temporary food service events

VENDING MACHINES
c:::l 41. Vending machines

=

c::J 32. Ice c::J 33. Sewage c::J 34. Plumbing c::J 35. Toilet facilities c::J 36. Handwashing facilities

7. Poultry cooking 8. Other animal cooking

MANAGER CERTIFICATION
c::J 42. Manager certification

c;:J

EQUJPMENTfUTENSILS
~ 22. Refrigeration c:::l 23. Sinks c:::J 24. Ice storage/Counter-protector c:::l 25. Ventilation/Storage/Sufficient c:::l 26. Dishwashing facilities equipment

c::J 9. Least contactlReheating c::J 10. Food container c:::J II. Buffet requirements c::J 12. Self-service condiments

=

CERTIFICATES AND FEES
43. Certificates and fees

c::J 37. Garbage disposal c::J 38. Vermin control

INSPECTIONIENFORCEMENT
c;:J

44. InspectionlEnforcement

~--------------------------------------------------~------------~T7~~~-b~~~~~~~
c:::J 13. Reservice of food

ITEM NUMBERS

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STATE OF FLORIDA DEPARTMENT OF HEALTH ,
fOOD SERVICE INSPECTION REPORT

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PAGE

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PURPOSE:
ROUTINE
c::::J J\ETNSI'ECTlOl'l c::::J CHANGE OF OWNeR Cl CONSlJI,TAT10N c::::J OTHER

COUNTY HEALTH DEPARTMEN0'

CONSTRUCT
COMPLI\Tl'/T

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15.

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= = = = =

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COMMENTS AND INSTRUCTrONS
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STA TE OF FLORIDA DEPARTMENT OF HEAL Tn COUNTY PUBLIC HEAL TB UNIT
Identification
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iTATE OF FLORIDA D~ARTMENTOFHEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE INSPECT,lONREPORT

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'STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
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= = =

RElNSPECTlOlll

CJ CHANGE OF6WNER CONSULTATION OTHER

FOOD SERVICE INSPECTION REPORT

Incomplete Unsatisfactory' Correct Violations by .. Next Inspection

= 8:00AM

on:

c:J c:J 16. Poisonous/Toxic materials

2. Stored temperature
3. No further cooking/Rapid cooling

PERSONNEL
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Sinks

t:::l23.

c:J 24. Ice storage/Counter-protector c:J 25, Ventilation/Storage/Sufficient equipment _ 38. Vermin control

.HEALTHDEPARTMENT INSPECTOR:"'_-4b..~--",o;...::,='9~~","--,dA"""'--;:::>'T""'-'7'"'--(;(5J#Y.OFREPORT RECEIVEDBY' -----""?'''C-..:;_~'''<:-+---,b"'''''''---,.L-:~---~-DH Form 4023, 1105 {Obsoletes Previous Editions)
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c::::J REINSPECTION c::::J CHANGE OF OWNER c::::J CC)NSUtTATION c::::J OTHER

STATE OF FLORIDA

ROUTINE CONSTRUCT. COMPLAINT QASURVEY

FOOD SERVICE INSPECTION REPORT

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6. Pork cooking

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AND CONTROLS 3 L Water supply

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= = =
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VENDING MANAGER

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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE JNSI'ECTION REPORT

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COMPLAINT

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ANP,t:~('OJKOLS

2~. Cleanliness of equipment

(,LNking,/JtljH{i

c::J

17. ExcillS,(;ll Ili'I",,,onnJ I & Ck<U1llflC~',
j~.

=
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:W. I f~l'ldw1;hing_

o nice

c::J ? I. lIiHlJllt,~ ~I( ishware d

= 11.Sew'g"

9

Lenst

COn'ACtlR"hC'~llt·_(:
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10, FooJcnnt\in"V"'O

12, Sclf·$Cl'ViCt: condiments

= = = =

F:QtJ IPM FoNT Il'l'ENSILS

=
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INSPECTION
c::J 44. lnspcctio

F.NFORCEI\JBN~

. COMMENTS AND iNSTRUCTIONS (continue on attached sheet)
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ESTAAI I~HME.NT!F6~IIITV

PURPOSE:
QIIa

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
c:::J REINSPECTION c:::J CHANGE OF OWNER c:::J CONSULTATION c:::J OTHER

ROUTINE

=

=

= CONSTRUCT.
COMPLAINT QASURVEY

FOOD SERVICE INSPECTION REPORT

Correct Violations by __ Next Inspection = 8:00AM on:

Nursing Detention Lounge Civic Movie Residen. Child Limited
Other

c!:J.
~.'-<

c8:J~ dtllliOi

~ itllM

ct2JAA

=
= = =
~

FOODSUPP~
L Sources,

EI!!\.J

FOOD PROT.F:fiTiON
2. Stored te~rature No furthc:a»okingfRapid cooling

= 4.Thawin~

5. Raw fruits

--

C:-::J

=

=

6. Pork cooking
7

Poultry cooking

= = = PERSONNEL = = = = = = = = =
r: ~ 23. Sinks

14. Sneeze guards 15. Transportation 16. PoisonousIToxic offood materials

= = =
~

27. Design and fabrication 28. Installation and location 29. Cleanliness of equipment

OTHER FACILITIES AND OPERATIONS
~ 39. Other faciuties and operations

30. Methods of washing

TEMPORARY FOOD

17. Exclusion of personnel

SANITARY FACILITIES

18. Cleanliness 19. Tobacco use

20. Handwashing 21. Handling of dishware

=
facilitiesIThermometers

= 31. Water-supply
32.lce c:::J 33. Sewage 34. Plumbing,

AND CONTJl_QtS

= = = =

8. Other animal cooking 9. Least contact/Reheating 10. Food container II Buffet requirements 12 Self-service condiments of food

EQUIPMENTIUTENSILS
22. Refrigeration

=
=
~ equipment

35. Toilet facilities. 36. Handwasbing facilities

24. Ice storage/Counter-protector 25. Ventilation/Storage/Sufficient 26. Dishwashing facilities

= 13 Reservice
ITEM NUMBERS

=

c:::J 37. Garbage disposal 38. Vermin control

= VENDING MACHINES = MANAGER CERTIFICATION = CERTIFICATES AND FEES = INSPECTIONIENFORCEMENT =
40, Temporary food service events 41. Vending machines 42. Manager certification

SERVICE EVENTS

43. Certificates and fees

44. Inspection/Enforcement

,t_".

/(~<

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COMMENTS AND INSTRUCTIONS
(continue on attached sheet)

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PHONE: DATE

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COPY OF REPORT RECEIVED
DH

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Form 4023. 1/05 (Obsoletes Previous Editions)

... /~
PURPOSE: .Ffiiil ROUTINI:

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
FOOD SERVICE INS'IECTION REPORT

~

= =

CONSTRUCT COMPLAINT QASURVEY

=

= CONSULTATION = OTHER

=

= REINSPECTION
CHANGE OF OWNER

Satisfa~t(try..,._ Incomplete Unsatisfactory Correct Violations b; _ Next Inspection = 8:00AM on:

cX:Ja:.'
atJa5J dDlIWI
d:Q~

cdJl2t'Il

= Detention = Lounge, = Civic

=

Nursing

=

Movie

l1.:1J~

=
c::J
.j

15. Transportation 16. Poisonous/Toxic

offood materials

PERSONNEL
Fbawuu, Raw fruits Pork cookmg 7 Poultry cookmg Other animal cooking Least contact/Reheating Food container Buffet requirements Self-service Rcscrvice condiments of food

j

=

=

28. Installation and location 29. Cleanliness of",q).lipmery~ .

=
d

AND OPERATIONS

P,/) -: ""',

39. Other facilities andoperaiiorn;

EiiiiI 30. Methods of_i$,:.,

TEMPORARY FOOD /1 II-(,:j-~~:, SERVICE EVENTS _
rr '/ ( -: ,';

= 19. Tobacco use = 20. Handwashing

=
c::::J

17 Exclusion

(If persounc!

SANITARY FACILITtltS

18. Cleanl1ne"

= 31. Water.supply
U
32. Ice

AND CONTROLS

40,Tslplwraryfood servloe events

=
. (

=

= 23. Sinks = 24. Ice storage/Counter-protector
26, Dishwashing
_.-/

= =

21. Handling of dishwarc

EQUIPMENT/UTENSILS
22. Refrigeration facilitieslThennometers

=

= 33. Sewage

=
'~'~'"

VElN)J~;MACHlNES
41. Ve~ding,machines /'

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/7 .:

.c {' rr i ,4!~(

,MANAGER
.,., ~

CERTIFICATIONJ,(.
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=

34. Plumbing 35. Toilet facilities

42. Manager certilicatiB

25. Ventilation/Storage/Sufficient facilities

equipment

=

=

= 36. Handwashing

facilities

=

CERTIFICATES AND FEES - '/
43. Certificates and fees

r Q_
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37, Garbage dispesal 38. Vermin control

INSPECfIONIENFOR(;;EMENT

J-.// (".

ITEM Nll\lBERS

CQMMENTS
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,.(contlnue

AND INSTRUCTIONS
011

attached sheet)

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,E!fTABUSHMENTIFACILITY

= = = =

PURPOSE:
ROUTINE CONSTRUCT COMPLAINT QASURVEY

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

= = =

~

REINSPECTION CHANGE OF OWNER CONSULTATION OTHER

FOOD SERVICE INSPECTION REPORT

Nursing cltJd:S c:!tJ t20I c6J125l c:7J" c5::lI201 Detention Lounge Civic Movie School Residen. Child Limited

ctba
c:7J13OI

c8J135!
~rml! 111ll~

c8J135!
cttJ filOI

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d::tJ6OI

FOOD SUPPLIES
c::J I Sources, etc

c::J
c:::J c::J

14. Sneeze guards 15 Transportation 16. Poisonous/Toxic of food materials

=
c:::J c:::J

= 2~

27.Design and fabrication
Installation and location of equipment 29. Cleanliness

OTHER FACILITIES AND OPERATIONS
c:J

FOOD PROTECTION
c:::J
c::J

39. Other facilities anJ opcratu.n-,

Stored temperature No further cooking/Rapid 4. Thawing cooling

PERSONNEL
c::J

30. Methods of washing

TEMPORARY FOOD SERVICE EVENTS
c:::J

=

17 Exclusion lB. Cleanliness
19.

of personnel

SANITARY FACILITIES

Raw fruits
Pork cooking Poultry cooking X Other animal cooking q Least contact/Reheating !() Food container Buffet requirements Self-service condiments

=
c::J c::J

Tobacco use

=
c::J c::J

AND CONTROLS
11 Water supply 32 Icc 3.3. Sewage 34 Plumbing 35. Toilet facilities 3(), Handwashing facilities

40. Temporary food service cvcut-,

VENDING MACHINES
c:::::J

20 Handwashing 21 Handling of dishware

4 J. Vending muchincs

EQUIPMENT/UTENSILS
c::J 22 Refrigeration facilities/Thermometers

=
c:::J c::J

MANAGER CERTIFICATION
c::J

42. Manager

certification

=
c::J c::J

c::J

23. Sinks 24. Ice storage/Counter-protector 25. Ventilation/Storage/Sufficient 26 Dishwashing facilities equipment

=

= 43. Certificates
c:::J

CERTIFICATES AND FEES
and fees

37. Garbage disposal

INSPECTION/ENFORCEM ENT
44. Inspection/Enforcement

c::J 3~. Vermin control

Reservice of food

ITEM '\l.MBERS

COMMENTS AND INSTRUCTIONS
(continue on attached sheet)

COP} OF RFI'ORT RECEIVED
DH Form 4023. 1/05

BY

(Obsoletes Previous

~SE:
..

= =

= CONSTRUCT = COMPLAINT
QASURVEY

ROUTINE

= = =

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
RElNSPECTION CHANGE OF OWNER CONSUCLUION

FOOD SERVICE INSPECTION REPORT

= OTHER

Incomplete Unsa tisfactory Correct Violations by Next Inspection 8:00AM on:

ri;;ATE

=

=

Gt:J d:tlI

r::S::H2Ot

®125J
r.:LJ~

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d:tJ ISO!

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= = = = = ~ = = = =
c::J c::J

Nllr~illg

Detenuon
LOllnge

Civic Movie School Residen. Child Limited

15, Transportation 16. Poisonous/Fox

of food ic materials

=
=

CS. Installation and location of equipment

AND OPERATIONS
c:=:J

c::=I 2tt. Cleanliness

39. Other facilities and operations

2. Stored temperature 3. No further cooking/Rapid cooling

PERSONNEL
c::J

30 Methods of washing

TEMPORARY SERVICE
c:::J

FOOD

=

17. Exclusion of personnel

SANITARY

FACILITIES

EVENTS MACHINES CERTIFICATION AND FEES

Rav v ' fruits Pork cooking Poultry cooking

= 20. Handwashing = 21 Handling of dishware = 22. Refrigeration = 23. Sinks
EQUIPMENT/UTENSILS
facilities/Thermometers

=

is.

Cleanliness

19. Tobacco use

=

AND CONTROLS
31 Water supply

40. Temporary food service e\'cnts

Other animal cooking 9. Least contact/Reheating

Buffet requirements Self-service Reservice condiments of food

=
c::J

24 lee storage/Counter-protector 25 Ventilation/Storage/Sufficient 26 Dishwashing facilities equipment

=

= = = = =

= 32. Ice = 33. Sewage

34. Plumbing 35. Toilet facilities 36. Handwashing facilities

37. Garbage disposal 3R. Vennin control

= = = =

VENDING MANAGER

41 Vending machines

42. Manager certification

CERTIFICATES

43. Certificates and fees

INSPECTION/ENFORCEMENT
44. lnspection/Enforcement

ITEM NUMBERS

COMMENTS

(continue on attached sheet)

AND INSTRUCTIONS

HEALTH DEPARTMENT

INSPECTOR

CO!'Y OF REPORT RECEIVED BY
DH Form 4023. 1/05 (Obsoletes Previous Editions)

I
------------

-

--

-

PURPOSE:

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

~

ROUTINE

= CONSTRUCT = COMPLAINT = QASURVEY =

= = = =

REINSPECTION CHANGE OF OWNER CONSULTATION OTHER

FOOO INSPECTION

SERVICE REPORT

-,"':",;~,

T

.""'.,

~;I'~ ~_."

~::

= Incomplete
Unsatisfactory Correct Violations by r:!!!t Next Inspection

= 8:00AM

on:

Nursing Detention Lounge Civic

Residen. Child Limited Other

=

OUT

OF BUSINESS

~~

)l'",'Ji

l

=
~

FOOD

SUPPLIES

I. Sources. etc. PROTECTION

FOOD

= = =
cooling

~f/ff.UTQtl 14. Sneeze guards 15. Transportation 16. Poisonous/Toxic of food materials

.. r::::::J

"jI

= = = = = = =
=

2. Stored temperature 3. No further cooking/Rapid 4. Thawing 5. Raw fruits 6. Pork cooking 7. Poultry cooking 8. Other animal cooking 9. Least contactlReheating

= 21. Handling

=

= = =

PERSONNEL 17. Exclusion of personnel 18. Cleanliness 19. Tobacco use 20. Handwashing of dishware

= =

=

27. Design antl"fabrication 28.~."$J,!lIlalion and location 29. "Cleanliness of equipment 30. Methods of washing FACILITIES

OTHER AND

FACILITIES

= 39. Other
TEMPORARY

OPERATIONS facilities and opersaans FOOD EVENTS

~

SANITARY

EQUIPMENTIUTENSILS

=

=II . Buffet requirements =12. Self-service condiments
13. Reservice of food ITEM NUMBERS

10. Food container

= = = =

~

22. Refrigeration 23.Sinks

facilitieslThermometers

= = = = =

AND CONTROLS 31. Water supply 32.lce 33. Sewage 34. Plumbing 35. Toilet facilities 36. Handwashing facili~

= = =

SERVICE

:t:.

40. Temporary food servi3ents MACHINES

VENDING

41. Vending machines

MANAGER

CERTIFICATION

42. Manager certification AND and fees

N

S>

24. Ice storage/Counter-protector 25. Ventilation/Storage/Sufficient 26. Dishwashing facilities COMMENTS (continue equipment

= =

~

= 43. Certificates
'~ECTIONIENFORCEMENT

CERTIFICATES

FEES

37. Garbage disposal 38. Vermin control

=

44. InspectioniEnforcement

AND

INSTRUCTIONS on attached sheet)

DH Form 4023, 1/05 (Obsoletes

Previous

Ed'

PURPOSE:

= = =
...

ROUTINE CONSTRUCT. COMPLAINT QASURVEY

=

=

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
REINSPECTION CHANGE OF OWNER

FOOD SERVICE INSPECTION REPORT

= CONSULTATION

=

OTHER

Satisfactory

= Unsatisfactory
Correct Violations by ~ Next Inspection

=

8:00AM

= Civic

= =

Lounge Movie

= = = = = =

FOOD SUPPLIES
I. Sources, etc.

FOOD PROTECTION
CjjIt 2. Stored temperature 3. No further cooking/Rapid 4. Thawing 5. Raw fruits 6. Pork cooking 7. Poultry cooking animal cooking contactfReheating cooling

= 16. PoisonousIToxic

= =

14. Sneeze guards 15. Transportation offood materials

= 29. Cleanliness
= 30. Methods

= =

27. Design and fabrication 28. Installation and location of equipment

OTHER FACILITIES

= 39. Other facilities
TEMPORARY

AND OPERA nONS
and operations

= 9. Least

= 8. Other

= = = =

= = = = = = = =
=

PERSONNEL
17. Exclusion of personnel 18. Cleanliness 19. Tobacco use 20. Handwashing 21. Handling of dish ware

of washing

FOOD

SANITARY FACILITIES

EQUIPMENTfUTENSILS
22. Refrigeration facilities/Thermometers

10. Food container II. Buffet requirements 12. Self-service 13. Rcservice condiments of food

= 23. Sinks

= = = = =
=

AND CONTROLS
31. Water supply 32. Ice 33. Sewage 34. Plumbing 35. Toilet facilities

= =
.

SERVICE EVENTS
40. Temporary food service events

= 41. Vending

VENDING MACHINES
machines

MANAGER CERTIFICATION
42. Manager certification

= 36. Handwashing·facilities
37. Garbage disposal 38. Vermin control

= 43. Certificates

CERTIFICATES AND FEES
and fees

24. Ice storage/Counter-protector 25. Ventilation/Storage/Sufficient 26. Dishwashing facilities equipment

=

=

INSPECTION/ENFORCEMENT
44.lnspectionlEnforcement

ITEM NUMBERS

COMMENTS AND INSTRUCTIONS
(continue on attached sheet)

= = =

PURPOSE: r:.- ROUTINE
CONSTRUCT COMPLAINT QASURVEY

= = = =

STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
REINSPECTION CHANGE OF OWNER CONSULTATION OTHER

FOOD SERVICE INSPECTION REPORT

=
=
~

= Lounge
Civic Movie School

=

Detention

=
_

00

S
= = 15. Transportation 16. PoisonousIToxic of food materials = = 28. Installation and location 29. Cleanliness of equipment of washing

o

I. Sources, etc.

FOOD PROTECTION

= =
= =

2. Stored temperature 3. No further cookinglRapid 4. Thawing cooling

PERSONNEL

= 30. Methods

=

ANDOPE~TION~,e:z

.;.

....

~t:

IvAPmfre
I->/IVf?w-.C

t'~aZ.?

I
_

= 5. Raw fruits
6. Pork cooking 7. Poultry cooking cooking

=
= =

=

17. Exclusion of personnel
18.

=

Cleanliness

19. Tobacco use 20. Handwashing 21 Handling of dishware

=
= facilities/Thermometers '" "\

SANITARY FACILITIES AND CONTROLS
31. Water supply

=
=

TEMPpRARY FOOP SERVICE EVENTS

wI (U'~ff( 3 ...e? ;:-m-f C? t I( 40. Tet1lparary'foodserviceeva! t tE 2(c- r
.

39. Other facilities and opera~ . . /l:.t

~

= 8. Other animal

=
= = =

=

9. Least contact/Reheating

~_
= =

10. Food container
II. Buffet requirements 12. Self-service condiments

..
=

EQUIPMENTIUTENSILS

22. Refrigeration
23. Sinks 24.lce

= ... =
~

= 32. Ice

VENDING MACHINEs-rI-vEET.
41~~~Ulgf11achmes

Azz;-;:;.

t'l'I/r(/C,rrv

P{'! 1.
f~

33. Sewage 34. Plumbing 35. Toilet facilities 36. Handwashing facilities

=-

=.
=43.

MANAGER CERTIFICA'~N
42 M anager cern ·fi~ . . . rcanon

"'t-./O WI (jv I A ;..
f2-.VII
/L 1-

q

~

~

CERTIFICATES AND FEES
Certificates 'and fees

Vv: " ~- r
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? r.-

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;>

n

_?, V

storage/Counter-protector

37. Garbage disposal 38. Vermin control

r.- 25. Ventilation/Storage/Sufficient
26. Dishwashing facilities

equipme~\.JiiI

=

INSPECfIONIENFORCEMENf!
44.lnspectionlEnforcernenfv.7

~A'/
t/

Ff?t!I:cA

13. Reservice of food

ITEM NUMBERS

COMMENTS

(continue on attached sheet)

AND INSTRUCTIONS

I..JELf)

2G

HWTH D,,"RrME'"

tssrtcron
Previous

0.
Editions)

cunOFREPORCRECFwm"
DH Form 4023 1/05 (Obsoletes

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- -. STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT

-- = _- _.__:.,: -

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.- =

_:__ ::_-'-

PURPOSE:
...

= CONSTRUCT = COMPLAINT = QASURVEY

ROUTINE

=

= REINSPECTION = CHANGE OF OWNER = CONSULTATION = OTHER

FOOD SERVICE INSPECTION REPORT

OTHER

= Incomplete
ZIP
.,

= Satisfactory
Correct Violations by Next Inspection = 8:00AM on:

.r : '

= Unsatisfactory

PERSONlN CHARGE
'I'"~ !,f "

PHONE(S0

!)b9cr -71'~:l

=

".D~T~
05

= = = =
c:::=J c::=J I Sourcc::;. cit: c::=J c:::=J

=

c=I

Nursing Detention Lounge Civic Movie Rcsiden Child Limited Other

a:+::2:J cZ:Jlc:::J
ic3J [~::J

ct:Jt:nct:Jp

06

07
08

= = =

09
10 11 12 13 14

~School

= OUT OF BUSINESS

14. Sneeze guards I), Transporr.uion 16.
POiSOIlOUS'

():'I~H)d

= 2k Installation
~

c::=J

27 Design and fabrication and location ofequipment

AND OPERATIONS
-.J
Js),

FOOl) PROTECTION
~ :::.Sh)rcd temperature No further cookinuRaprd
c::=J CJ c::::J c::::J c::::J c::::J ~ rh;I\\'jng

Toxic marcnals

coulinu

=
[JD c:::::l c:::::J c:::::J

PERSONNEL 17.Exclusion of personnel IX.Cleanliness
19. Tobacco use 20 HanJwJshlllg 21 Handling of dishwarc

=
Cl

:':9. Cleanliness

Other facilitIes and operations

30 Methods ofwashing

TEMPORARY FOOD SERVICE EYENTS
c:::=J

SANITARY FACILITIES AND CONTROLS
J J, Water supply ed:t- 32 Ice
c:::::J

-to,

Temporary

food sen icc events

5. Raw fruit-;
()

VENDING MACHlriI
c::::J ~ I Velldll1g JllJI..'hin~

Pork cookrug
cookmp

"7 I'ounrv ~

33 Sewage 14 Plumbing

~IAN.\GER CERTM'~\TION
c::=J 42. i\Llil<lgcr cl'!1ifi~nll

()tlh:r annual cooking
l'()JH;\Ct

EQUIPl\lENT/llTENSILS
~
c:::::J c::::J c::::J c::::::J

Y Least

Reheating

22 Refrigerauon 23 Sinks

taciliues.Thcrmomcters

I:ii:ii- 35. Toilet facilities

CERTI FICHES ,~
c::=J

FEES

~10

fUtlJ container

43, Certificates

and fees

2~ Icc storage-Counter-protector 15. VcnnlationStorageSufficient 20, Dishwaslung facilities equipment

c:::::J

37 Garbage disposal

INSPECTION/Ei'®RCEMENT
[::=:J

c::::J JR Vermin control

44,

Inspcction:[~cemeJl'

ITEM 'HJ\IBERS

COMMENTS

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AND INSTRUCTIONS
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OH Form 4023, 1:05 (Obsoletes

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FOCJu vt:HVICE
L·65606.;6.EASTERN BUSINESS FORMS. INC 38&758-4273

FOOD SER\/ICE

PURPOSE:
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STATE OF FLORIDA DEPARTMENT OF HEALTH COUNTY HEALTH DEPARTMENT
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ROUTINE CO'-iSTRCCT. COMPLAJfo;, QASURVEY OTIfER
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REGSPEcno;.; CHA'-iGE OF O\\'"ER CONSULTATION OTHER

FOOD SERVICE

I?'SPECTIOX REPORT

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ESTABLISHMENT
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CITY

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Nursing Detention

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:lib .3.5J 140l

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= Lounge
Civic Movie School

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Residen.
Child

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fOOD SUPPLIES
Sources. etc.

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14. Sneeze guards I~. Transportation of food 16. Poisonous/Toxic materials

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= 2. Stored temperature = .i. "0 Il1l111n cooking-Rapid
= 4. Thawing
5. Ra\\; fruits 6. Pork cooking 7. Poultry cooking R. Other animal cooking 9 Least contact Reheating 10. Food container II. Buffet requirements 12 Self-service condiments

FOOD PROTECTIO;-i

=
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28. Installation and location 29. Cleanliness of equipment 30. Methods of washing

OTHER FACILITIES AND OPERATIONS
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39. Other facilities and operations

cooling

=
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PERSO:\",t:L
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TEMPORARY FOOD

7. Exclusion of personnel

18. Cleanliness 19 Tobaccouse 20. Handwashing 21. Handling of dishware

=

SANITARY FACILITIES AND CONTROLS

= 40. Temporary

SERVICE EVENTS
food service events

=
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= 32. Ice
=
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31 Water

supply

=
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VENDING MACHINES
41 Vending machines

33. Sewage
34. Plumbing

MANAGER CERTIFICATION
42. Manager certification

= n Refrigeration
23. Sinks

EQUIPMENT/UTENSILS
Iacilities-Thermorneters

= 24. Ice storageCounter-protector
= 25. ventilationStorageSufficient = 26. Dishwashing facilities
equipment.=

= 35. Toilet facilities = 36. Handwashing facilities
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CERTIFICATES AND FEES
43. Certificates and fees

37. Garbage disposal 38. Vermin control

INSPECTTONIENFORCEMENT
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44.lnspectionfEnrorcement

13. Reservice of food

ITEM NUMBERS
..

COMMENTS

(continue on attached sheet)

AND INSTRUCTIONS

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