قائمة تقييم الغذاء

‫تعهد استالم أدوات‬ System: HSEMS
Form No.: HSE-00-00-00 Form Rev. No.: 0 Form Issue No.:1
Form Issue Date: 10-3-2022 Ref #: Date:
Food Safety Self-Inspection Checklist

Date__________________________________________
CFM/ PIC_____________________________________________________
IN OUT EMPLOYEE/CUSTOMER ILLNESS

1. All employees are trained as required on our Employee Illness Policy.
2. All employees have signed an Employee Illness Reporting Agreement and forms are
kept on-site.
3. Ill employees are excluded or restricted as required.
4. Reports of ill employees are made, as required, to Brown-Nicollet Environmental

Health and are entered onto Employee Illness Log as reported to Person In Charge.
5. All customer complaints of illness are addressed by CFM or PIC and reported
immediately as required.
IN OUT EMPLOYEE BEHAVIORS

6. All employees are trained on proper handwashing.
7. Handwashing is monitored.
8. Eating, drinking, or tobacco use is restricted in food areas.
9. Bare hand contact with ready-to-eat and ready-to-serve food items is restricted.
10. Facilities and supplies are adequate for proper handwashing.
11. Adequate supply of gloves is available to all employees.
IN OUT FOOD SUPPLY

12. Food is purchased from approved suppliers/no home prepared food.
13. Food is received at proper temperatures. Monitor receiving temperatures and log as
required.
14. Food items received are inspected, segregated and damaged food are discarded or
returned.
15. Itemized supplier records are maintained onsite, so they are readily available.
IN OUT PROTECTION of FOOD from CROSS-CONTAMINATION

16. Food items are stored properly to protect from cross-contamination, in coolers, and
food storage areas.
17. All food contact surfaces are properly sanitized between uses; including dishes and
utensils, food prep tables and preparation sinks.
18. Sanitizer effectiveness has been tested or monitored and recorded on logs as
required.
19. Proper scoops are available for service of ice and food, and they are stored properly.
IN OUT FOOD PROTECTION

20. Thermometers are calibrated on a regular basis according to manufacturer’s
specifications.
21. Final cooked temperatures of menu items are monitored and recorded as required.
22. All hot holding temperatures are maintained, monitored and recorded as required.
23. All cold holding temperatures are maintained, monitored and recorded as required.
24. Potentially hazardous food items are properly date marked and disposed of if date
has expired.
IN OUT CHEMICAL STORAGE

25. Toxic chemicals are properly labeled, stored and used in order to prevent
crosscontamination of food products and equipment.
26. Employees are properly trained on proper use of chemicals.
IN OUT PHYSICAL FACILITIES

27. All physical facilities are clean and maintained clean.
28. Safe potable water supply is available and protected from back-flow or back
siphonage.
29. Hot and cold water are available at all locations in the facility.
30. Deter insects, rodents or animals from facility.
31. Unauthorized persons are restricted from food preparation and storage areas.
OTHER:
32. ______________________________________________________________________________
33. ______________________________________________________________________________
34. ______________________________________________________________________________
ITEMS REQUIRING IMMEDIATE ATTENTION (NOTE ITEM #):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
To obtain additional copies of this form, visit our website at:
www.co.nicollet.mn.us>Departments>Brown-Nicollet Environmental Health>Licensed

Establishments>Food and Beverage Establishments>Documents and Resources>Food and Beverage
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‫تعهد استالم أدوات‬ System: HSEMS

Form No.: HSE-00-00-00 Form Rev. No.: 0 Form Issue No.:1

Form Issue Date: 10-3-2022 Ref #: Date:

Food Safety Self-Inspection Checklist

IN OUT EMPLOYEE/CUSTOMER ILLNESS

4. Reports of ill employees are made, as required, to Brown-Nicollet Environmental

IN OUT EMPLOYEE BEHAVIORS

8. Eating, drinking, or tobacco use is restricted in food areas.

10. Facilities and supplies are adequate for proper handwashing.

11. Adequate supply of gloves is available to all employees.

IN OUT FOOD SUPPLY

Form No.: HSE-00-00-00 Form Rev. No.: 0 Form Issue No.:1

Form Issue Date: 10-3-2022 Ref #: Date:

IN OUT PROTECTION of FOOD from CROSS-CONTAMINATION

IN OUT FOOD PROTECTION

IN OUT CHEMICAL STORAGE

IN OUT PHYSICAL FACILITIES

Form No.: HSE-00-00-00 Form Rev. No.: 0 Form Issue No.:1

Form Issue Date: 10-3-2022 Ref #: Date:

30. Deter insects, rodents or animals from facility.

ITEMS REQUIRING IMMEDIATE ATTENTION (NOTE ITEM #):

Form No.: HSE-00-00-00 Form Rev. No.: 0 Form Issue No.:1

Form Issue Date: 10-3-2022 Ref #: Date:

To obtain additional copies of this form, visit our website at:

www.co.nicollet.mn.us>Departments>Brown-Nicollet Environmental Health>Licensed

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