ASSURANCE OF CONFIDENTIALITY All information provided will be accorded confidential treatment and will be used for statistical purposes only. the statistics will be presented in such a manner that no individual person or facility can be identified. GRAND TOTAL 43-46 h. TOTAL 60-82 SM-750-3 (Page 1) 0-73 OMB NO. 68-S73043 56 59 793 2 Covered by No. Sa above. 2017] Don't include hours for eating and sleeping 7. COMMENTS HSM-750-3 (Page 2) 6-73 SIGNATURE TASSURANCE OF CONFIDENTIALITY All information provided will be accorded confidential treatment and will be used for statistical purposes only; the statistics will be presented in such a manner that no individual person or facility can be identified. % UNSATISFACTORY % Day Yr Mo, 23-25 HSM - 750 - 2 5-73 (Page 1) OMB NO. 68-S73043 (Continued on Page 2) O w Not Done NO N/A oO w Not Done YES . 1 32 O NO -2 N/A 1 -2 7 O 9 ооо оооч 10 0 35 0 113 Walls and Ceiling Not Easily Cleanable 11 O оооооо ro o o o o o ooo 12 O Other Improper Facilities or Operations Describe 85. Single Fire Exit 86. Unmarked Fire Exits 87. Fire Extinguishers Not Available or Improper Type 88. Fire Extinguishers Out of Date 89. Structurally Unsafe 90. Insanitary Condition of Kitchen Area 91. Food Adulterated or Spoiled 92. Unapproved Food Source 93. Inadequate Facilities For 94. Poisonous/Toxic Material 95. Persons With Apparent 96. inadequate Hygiene of Food Handler 97. Equipment Improperly Constructed or Installed 98. Utensils Improperly Stored 99. Dishwashing Facilities 100. Tableware Not Sanitized 101. Single Service Articles Improperly Stored 102. Hot and Cold Running Water 103. Waterheater Without 104. Cross Connections 105. Accumulation of Grease on 106. Toilet and Lavatory with 107. Garbage Not Stored in Adequate Number of Approved 108. Garbage Not Removed From Kitchen Daily 109. Inadequate Insect and Rodent Control INSPECTOR'S SIGNATURE |
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