Montgomery County Health Department 1119'1 Illinois Route 185 Hillsboro IL 62049
Division of Environmental Health (217) 532-2001
Retail Food Sanitary Inspection Report Establishment Address
Establish()~ode
City
Purpose
....••••
.(Fi
Follow-up . '..
f"::.
Compliant with tne Smoke-Free Illinois Act?
~
0~ NO (circle one)
Pre-opening
Smoking
.;~zt~;'llth,;"
. •.....
18 IN OU~ NO Propercoolingtime&temperature
ou'twA'
2~
i l rN. Oersonal .p...e. r..e..a.hygiene ..ti.n...g...'.t..a. stin, .g, cleanliness dr. inki.ng.• ' tobacco use and
-.-i
Educational
.fQOPE30Rfstr::IU..,NI::~SRISI< FA.CTORS AND PU8L1CHI::f\I:1IH INTf;:.R\lENTION9
compliance status (IN, OUT, N/O, N/A) for each numbered item IN=in compliance OUT=out of compliance N/O=not observed N/A=not applicable Compliance Status
4 5
Time in
JJJsne.ction (circle one)'
0
CRout~
3
ct :l\ '\ ('. . ~
~
Zip
lj)~1J~t "
Owner/Agent
1
Risk
8points<
NO Proper date marking & disposition of PHF
OUiN/)} NO Time as a public health control: approved procedure & records
22 IN
.. .•
Proper cold holding temperature
i1W OUT N/A
;. (
".
. ".
23 IN OU~
Hands clean, handwashing procedures
.'.•: . . . ".,.;;,
: . e . Q V I S O r y . : . . . · 3 points Consumer advisory provided for raw or undercooked foods
Highly$llllcepnp(e;E'opuJ;ilio'f'lfl' '. . " .
.•••.•
.&PQin.t$· ...... .
24 IN OUTct!{6)~roper foods used for susceptible populations /~"
9 10
UT
.... Food obtained from approved source
!!i OUT
N/A ~O Food received at proper temperature
11 INpUT
Food in good condition, safe, unadulterated
12 IN OU1(NaII
Required records available; shellstock tags
25
14 II{ OUT
