YE

SN

O

SM

OK

E-F

RE

E A

IR A

CT

15R

“No

Smok

ing

or U

sing

Elec

tron

ic C

igar

ette

s” si

gn n

ot c

onsp

icuo

usly

pos

ted.

Hea

lth w

arni

ng n

ot p

rese

nt o

n “S

mok

ing

Perm

itted

” sig

n.

15S

“Sm

okin

g or

Usin

g El

ectr

onic

Cig

aret

tes P

erm

itted

” sig

n no

t con

spic

uous

ly p

oste

d. H

ealth

war

ning

not

pre

sent

on

“Sm

okin

g Pe

rmitt

ed”

sign.

15T

“Sm

okin

g is

Proh

ibite

d in

All

Area

s of t

his H

otel

(Mot

el),

Exce

pt in

Gue

st R

oom

s Des

igna

ted

as S

mok

ing

Roo

ms.

Plea

se E

xtin

guish

You

r Cig

aret

te, C

igar

or P

ipe,

or E

lect

roni

c C

igar

ette

” sig

n no

t con

spic

uous

ly p

oste

d. H

ealth

war

ning

not

pre

sent

on

“Sm

okin

g Pe

rmitt

ed”

sign.

15U

Size

of t

he le

tterin

g of

the

“Sm

okin

g Pe

rmitt

ed A

nd E

lect

roni

c C

igar

ette

Use

Per

mitt

ed”

sign

exce

eds t

hat o

f the

“N

o Sm

okin

g/N

o El

ectr

onic

Cig

aret

te U

se”

sign.

15V

“No

Smok

ing/

No

Elec

tron

ic C

igar

ette

Usa

ge”

mes

sage

not

show

n on

mot

ion

pict

ure

scre

en.

15W

Asht

rays

in sm

oke-

free

area

(s).

15X

Ope

rato

r fai

led to

mak

e go

od fa

ith e

ffort

to in

form

smok

ers o

f the

Sm

oke-

Free

Air

Act p

rohi

bitio

n of

smok

ing

or u

sing

elect

roni

c ci

gare

ttes.

Smok

ing

perm

itted

in a

n ar

ea w

here

it

is pr

ohib

ited.

15Y

Smok

ing

use

perm

itted

and

/or a

llow

ed in

smok

ing

proh

ibite

d ar

eas u

nder

the

cont

rol o

f the

ope

rato

r.

15Z

Smok

ing

and

elec

tron

ic c

igar

ette

use

wor

kpla

ce p

olic

y in

adeq

uate

, not

pos

ted

or n

ot p

rovi

ded

to e

mpl

oyee

s.

15A

AU

se o

f tob

acco

pro

duct

on

scho

ol p

rem

ises (

at o

r bel

ow th

e 12

th-g

rade

leve

l) ob

serv

ed.

15A

BFa

ilure

to re

gist

er re

tail

toba

cco

or e

lect

roni

c ci

gare

tte st

ore.

SA

LE

OF

HE

RB

AL

CIG

AR

ET

TE

S,

TO

BA

CC

O H

EA

LT

H W

AR

NIN

G A

ND

SM

OK

ING

CE

SS

AT

ION

15A

CSa

le o

f her

bal c

igar

ette

s to

min

ors o

bser

ved.

RE

ST

RIC

TIO

N O

N T

HE

SA

LE

OF

CE

RT

AIN

FL

AV

OR

ED

TO

BA

CC

O

15A

DA

flavo

red

toba

cco

prod

uct s

old

or o

ffere

d fo

r sal

e in

an

esta

blish

men

t oth

er th

an a

toba

cco

bar.

15A

EO

rigin

al la

bel f

or to

bacc

o or

non

-toba

cco

prod

ucts

for s

mok

ing

sold

or o

ffere

d fo

r sal

e no

t mai

ntai

ned

on si

te.

AR

TIF

ICIA

L T

RA

NS

FA

T

16A

A fo

od c

onta

inin

g ar

tifici

al tr

ans f

at, w

ith 0

.5 g

ram

s or m

ore

of tr

ans f

at p

er se

rvin

g, is

bei

ng st

ored

, dist

ribut

ed, h

eld

for s

ervi

ce, u

sed

in p

repa

ratio

n of

a m

enu

item

or s

erve

d.

16B

The

orig

inal

nut

ritio

nal f

act l

abel

s and

/or i

ngre

dien

t lab

el fo

r a c

ooki

ng o

il, sh

orte

ning

or m

arga

rine

or fo

od it

em so

ld in

bul

k or

acc

epta

ble

man

ufac

ture

r’s d

ocum

enta

tion

not m

aint

aine

d on

site

. C

AL

OR

IE M

EN

U L

AB

EL

ING

16C

Cal

oric

con

tent

not

pos

ted

on m

enus

, men

u bo

ards

or f

ood

tags

, in

a fo

od se

rvic

e es

tabl

ishm

ent t

hat i

s 1 o

f 15

or m

ore

outle

ts o

pera

ting

the

sam

e ty

pe o

f bus

ines

s nat

iona

lly u

nder

com

mon

ow

ners

hip

or c

ontr

ol, o

r as a

fran

chise

or d

oing

bus

ines

s und

er th

e sa

me

nam

e, fo

r eac

h m

enu

item

that

is se

rved

in p

ortio

ns, t

he si

ze a

nd c

onte

nt o

f whi

ch a

re st

anda

rdize

d.

16E

Cal

oric

con

tent

rang

e (m

inim

um to

max

imum

) not

pos

ted

on m

enus

and

or m

enu

boar

ds fo

r eac

h fla

vor,

varie

ty a

nd si

ze o

f eac

h m

enu

item

that

is o

ffere

d fo

r sal

e in

diff

eren

t flav

ors,

varie

ties a

nd si

zes.

16F

Spec

ific

calo

ric c

onte

nt o

r ran

ge th

ereo

f not

pos

ted

on m

enus

, men

u bo

ards

or f

ood

tags

for e

ach

men

u ite

m o

ffere

d as

a c

ombi

natio

n m

eal w

ith m

ultip

le o

ptio

ns th

at a

re li

sted

as

singl

e ite

ms.

SO

DIU

M M

EN

U L

AB

EL

ING

16J

Sodi

um w

arni

ng ic

on n

ot p

oste

d on

men

us, m

enu

boar

ds o

r foo

d ta

gs fo

r foo

d ite

ms t

hat c

onta

in 2

,300

mg

or m

ore

of so

dium

in a

food

serv

ice

esta

blish

men

t tha

t is 1

of 1

5 or

mor

e ou

tlets

oper

atin

g th

e sa

me

type

of b

usin

ess n

atio

nally

und

er c

omm

on o

wne

rshi

p or

con

trol

, or a

s a fr

anch

ise o

r doi

ng b

usin

ess u

nder

the

sam

e na

me,

for e

ach

men

u ite

m th

at is

serv

ed in

por

tions

, th

e siz

e an

d co

nten

t of w

hich

are

stan

dard

ized.

16K

Sodi

um w

arni

ng ic

on p

oste

d on

men

us, m

enu

boar

ds o

r foo

d ta

gs fo

r foo

d ite

ms t

hat c

onta

in 2

,300

mg

or m

ore

of so

dium

is n

ot a

bla

ck a

nd w

hite

equ

ilate

ral t

riang

le; a

nd/o

r the

equ

ilate

ral

tria

ngle

is n

ot a

s wid

e as

it is

tall,

and

/or i

s not

equ

al in

hei

ght t

o th

e la

rges

t let

ter i

n th

e fo

od it

em’s

nam

e, a

s disp

laye

d on

the

men

u, m

enu

boar

d or

tag.

16L

Sodi

um w

arni

ng st

atem

ent n

ot p

oste

d co

nspi

cuou

sly a

t the

poi

nt o

f pur

chas

e. “

War

ning

: [ic

on im

age]

indi

cate

s tha

t the

sodi

um (s

alt)

cont

ent o

f thi

s ite

m is

hig

her t

han

the

tota

l dai

ly

reco

mm

ende

d lim

it (2

,300

mg)

. Hig

h so

dium

inta

ke c

an in

crea

se b

lood

pre

ssur

e an

d ris

k of

hea

rt d

iseas

e an

d st

roke

.”A

DM

INIS

TR

AT

ION

AN

D D

OC

UM

EN

TA

TIO

N

18A

Cur

rent

val

id p

erm

it, re

gist

ratio

n or

oth

er a

utho

rizat

ion

to o

pera

te e

stab

lishm

ent n

ot a

vaila

ble.

18B

Doc

umen

t iss

ued

by th

e Bo

ard

of H

ealth

, Com

miss

ione

r or D

epar

tmen

t unl

awfu

lly re

prod

uced

or a

ltere

d.

18C

Not

ice

of th

e D

epar

tmen

t or B

oard

of H

ealth

mut

ilate

d, o

bstr

ucte

d or

rem

oved

.

18D

Failu

re to

com

ply

with

an

Ord

er o

f the

Boa

rd o

f Hea

lth, C

omm

issio

ner o

r Dep

artm

ent.

18E

Failu

re to

repo

rt o

ccur

renc

es o

f sus

pect

ed fo

od-b

orne

illn

ess t

o th

e D

epar

tmen

t.

18F

Perm

it no

t con

spic

uous

ly d

ispla

yed.

18G

Food

Pro

tect

ion

Cer

tifica

te n

ot a

vaila

ble

for D

epar

tmen

t ins

pect

ion.

18H

Failu

re o

f eve

nt sp

onso

r to

excl

ude

vend

or w

ithou

t a c

urre

nt v

alid

per

mit

or re

gist

ratio

n. O

pera

tor o

f sha

red

kitc

hen

allo

wed

unp

erm

itted

cat

erer

or o

ther

use

r; or

faile

d to

pro

vide

cop

y of

ag

reem

ent b

etw

een

oper

ator

and

use

r.

18I

Failu

re to

pro

duce

pes

t man

agem

ent c

ontr

act;

failu

re to

kee

p re

cord

s sho

win

g ex

isten

ce o

f con

trac

t at e

stab

lishm

ent.

18J

Una

ppro

ved

outd

oor,

stre

et o

r sid

ewal

k co

okin

g.

SIG

NA

GE

20A

Food

alle

rgy

info

rmat

ion

post

er n

ot c

onsp

icuo

usly

pos

ted

whe

re fo

od is

bei

ng p

repa

red

or p

roce

ssed

by

food

wor

kers

.

20B

Food

alle

rgy

info

rmat

ion

post

er n

ot p

oste

d in

lang

uage

und

erst

ood

by a

ll fo

od w

orke

rs.

20C

Food

alle

rgy

post

er d

oes n

ot c

onta

in te

xt p

rovi

ded

or a

ppro

ved

by D

epar

tmen

t.

20D

“Cho

king

firs

t aid

” po

ster

not

pos

ted.

“Alc

ohol

and

pre

gnan

cy”

war

ning

sign

not

pos

ted.

“R

esus

cita

tion

equi

pmen

t: ex

hale

d ai

r res

usci

tatio

n m

asks

(adu

lt &

ped

iatr

ic),

late

x gl

oves

” sig

n no

t po

sted

.20E

Lette

r gra

de o

r “G

rade

Pen

ding

” ca

rd n

ot c

onsp

icuo

usly

pos

ted

and

visib

le to

pas

sers

by.

20F

Cur

rent

lette

r gra

de o

r “G

rade

Pen

ding

” ca

rd n

ot p

oste

d.

20G

Food

Pro

tect

ion

Cer

tifica

te n

ot a

vaila

ble

for i

nspe

ctio

n.

NU

ISA

NC

E A

ND

MIS

CE

LL

AN

EO

US

22A

Nui

sanc

e cr

eate

d or

allo

wed

to e

xist

. Fac

ility

not

free

from

uns

afe,

haz

ardo

us, o

ffens

ive

or a

nnoy

ing

cond

ition

s.

22C

Bulb

not

shie

lded

or s

hatte

rpro

of, a

nd/o

r end

caps

or o

ther

dev

ices

not

pro

vide

d in

are

as w

here

ther

e is

extre

me

heat

, tem

pera

ture

cha

nges

, or w

here

acc

iden

tal c

onta

ct m

ay o

ccur

.

22D

Plas

tic c

onta

iner

s with

mic

row

ave

safe

mar

king

s not

use

d fo

r hea

ting

food

.

22E

ROP

proc

essin

g eq

uipm

ent n

ot a

ppro

ved

by th

e D

epar

tmen

t.

22F

Misb

rand

ed, m

islab

eled

pac

kage

d fo

od p

rodu

cts.

Bure

au o

f Foo

d Sa

fety

and

Com

mun

ity S

anita

tion

SE

LF-I

NSP

EC

TIO

N W

OR

KSH

EE

T F

OR

FO

OD

SE

RVIC

E E

STA

BLIS

HM

EN

TS c

ont.

*Pu

blic

Hea

lth H

azar

ds (P

HH

) mus

t be

corr

ecte

d im

med

iate

ly+

Pre-

perm

it Se

rious

(PPS

) Vio

latio

ns th

at m

ust b

e co

rrec

ted

befo

re p

erm

it is

issue

d

Bure

au o

f Foo

d Sa

fety

and

Com

mun

ity S

anita

tion

Con

tact

Info

rmat

ion

Phon

e: 2

12-6

76-1

600

Fax:

212

-676

-166

6 W

eb: n

yc.g

ov/h

ealth

Mic

hael R

. B

loom

berg

Mayo

r

Thom

as

Farl

ey,

M.D

., M

.P.H

.C

om

mis

sioner

Michael R. BloombergMayor

Thomas Farley, M.D., M.P.H.Commissioner

CO

ND

ITIO

N

OB

SE

RV

ED

Self-Inspection Worksheetfor Food Service Establishments

June 2016

Bureau of Food Safety and Community SanitationSELF-INSPECTION WORKSHEET FOR FOOD SERVICE ESTABLISHMENTS

PART ONE – SCORED VIOLATIONS

CRITICAL VIOLATIONSCONDITIONS

SCOREI II III IV V

FOOD TEMPERATURE2A* Food not cooked to required minimum temperature:

• Poultry, meat stuffing, stuffed meats > 165°F for 15 seconds • Ground meat and food containing ground meat > 158°F for 15 seconds • Pork, any food containing pork > 155°F for 15 seconds • Rare roast beef, rare beefsteak except per individual customer request > required temperature and time • All other foods except shell eggs per individual customer request > 145°F for 15 seconds

– – – 10 28

2B* Hot food item not held at or above 140°F. 7 8 9 10 282C Hot food item that has been cooked and refrigerated is being held for service without first being reheated to 165°F or above within 2 hours. 5 6 7 8 –2D Precooked potentially hazardous food from commercial food processing establishment that is supposed to be heated, but is not heated to 140°F within 2 hours. 5 6 7 8 –2E Whole frozen poultry or poultry breasts, other than a single portion, is being cooked frozen or partially thawed. 5 6 – – –2F Meat, fish or molluscan shellfish served raw or undercooked without prior notification to customer. – – – 8 –2G* Cold food item held above 41°F (smoked fish and reduced oxygen packaged foods above 38°F) except during necessary preparation. 7 8 9 10 282H* Food not cooled by an approved method whereby the internal product temperature is reduced from 140º F to 70º F or less within 2 hours,

and from 70°F to 41°F or less within 4 additional hours. 7 8 9 10 28

2I Food prepared from ingredients at ambient temperature not cooled to 41°F or below within 4 hours. 5 6 7 8 –2J* Reduced oxygen packaged (ROP) foods not cooled by an approved method whereby the internal food temperature is reduced to 38°F within two hours of

cooking and if necessary further cooled to a temperature of 34°F within six hours of reaching 38°F. 7 8 9 10 28

FOOD SOURCE3A* Food from unapproved or unknown source or home canned. Reduced oxygen packaged (ROP) fish not frozen before processing; or ROP foods prepared on

premises transported to another site. – – – 10 28

3B* Shellfish not from approved source, improperly tagged/labeled; tags not retained for 90 days. – – – 10 283C* Eggs found dirty/cracked; liquid, frozen or powdered eggs not pasteurized. 7 8 9 10 283D* Canned food product observed swollen, leaking or rusted, and not segregated from other consumable food items. 7 8 9 10 283E* Potable water supply inadequate. Water or ice not potable or from unapproved source. Cross connection in potable water supply system observed. – – – 10 283F* Unpasteurized milk or milk product present. – – – 10 283G Raw food not properly washed prior to serving. 5 6 7 8 –

FOOD PROTECTION4A Food Protection Certificate not held by supervisor of food operations. – – – – 104B* Food worker prepares food or handles utensil when ill with a disease transmissible by food, or has exposed infected cut or burn on hand. – – – 10 284C* Food worker does not use proper utensil to eliminate bare hand contact with food that will not receive adequate additional heat treatment. 7 8 9 10 284D* Food worker does not wash hands thoroughly after using the toilet, coughing, sneezing, smoking, eating, preparing raw foods or otherwise contaminating hands. – – – 10 284E* Toxic chemical improperly labeled, stored or used such that food contamination may occur. 7 8 9 10 284F* Food, food preparation area, food storage area, area used by employees or patrons contaminated by sewage or liquid waste. – – – 10 284G* Unprotected potentially hazardous food re-served. – – – 10 284H* Raw, cooked or prepared food is adulterated, contaminated, cross-contaminated or not discarded in accordance with HACCP plan. 7 8 9 10 284I Unprotected food re-served. 5 6 7 8 –4J Appropriately scaled metal stem-type thermometer or thermocouple not provided or used to evaluate temperatures of potentially hazardous foods

during cooking, cooling, reheating and holding. – – – 8 –

4K Evidence of rats or live rats present in facility’s food and/or non-food areas. 5 6 7 8 284L Evidence of mice or live mice present in facility’s food and/or non-food areas. 5 6 7 8 284M Live roaches present in facility’s food and/or non-food areas. 5 6 7 8 284N Filth flies or food/refuse/sewage-associated (FRSA) flies present in facility’s food and/or non-food areas. Filth flies include house flies,

little house flies, blow flies, bottle flies and flesh flies. Food/refuse/sewage-associated flies include fruit flies, drain flies and Phorid flies. 5 6 7 8 28

4O Live animals other than fish in tank or service animal present in facility’s food and/or nonfood areas. 5 6 7 8 –

FACILITY DESIGN5A* Sewage disposal system improper or unapproved. – – – 10 285B* Harmful, noxious gas or vapor detected. CO > 13 ppm. – – – 10 285C+ Food contact surface improperly constructed or located. Unacceptable material used. 7 8 9 10 285D+ Hand-washing facility not provided in or near food preparation area and toilet room. Hot and cold running water at adequate pressure to

enable cleanliness of employees not provided at facility. Soap and an acceptable hand-drying device not provided. – – – 10 28

5E+ Toilet facility not provided for employees or for patrons when required. – – – 10 285F+ Insufficient or no refrigerated or hot holding equipment to keep potentially hazardous foods at required temperatures. – – – 10 285G+ Properly enclosed service/maintenance area not provided. (Mobile Food Commissary) – – – 10 285H+ No facilities available to wash, rinse and sanitize utensils and/or equipment. – – – 10 285I+ Refrigeration used to implement HACCP plan not equipped with an electronic system that continuously monitors time and temperature. – – – 10 28

PERSONAL HYGIENE & OTHER FOOD PROTECTION6A Personal cleanliness inadequate. Outer garment soiled with possible contaminant. Effective hair restraint not worn in an area where food is prepared. 5 6 7 8 –6B Tobacco use, eating or drinking from open container in food preparation, food storage or dishwashing area observed. 5 6 7 8 –6C Food not protected from potential source of contamination during storage, preparation, transportation, display or service. 5 6 7 8 –6D Food contact surface not properly washed, rinsed or sanitized after each use and following any activity when contamination may have occurred. 5 6 7 8 –6E Sanitized equipment or utensil, including in-use food-dispensing utensil, improperly used or stored. 5 6 7 8 –6F Wiping cloths soiled or not stored in sanitizing solution. 5 6 7 –6G* HACCP plan not approved or approved HACCP plan not maintained on premises. – – – 10 286H Records and logs not maintained to demonstrate that HACCP plan has been properly implemented. – – – – 286I Food not labeled in accordance with HACCP plan. – – – 10 28

OTHER CRITICALS7A Duties of an officer of the Department interfered with or obstructed. – – – – 28

CRITICAL VIOLATIONS TOTAL

GENERAL VIOLATIONSCONDITIONS

SCOREI II III IV V

VERMIN / GARBAGE8A Facility not vermin proof. Harborage or conditions conducive to attracting vermin to the premises and/or allowing vermin to exist. – – 4 5 –8B Covered garbage receptacle not provided or inadequate, except that garbage receptacle may be uncovered during active use.

Garbage storage area not properly constructed or maintained; grinder or compactor dirty. 2 3 4 5 –

8C Pesticide use not in accordance with label or applicable laws. Prohibited chemical used/stored. Open bait station used. 2 3 4 5 28

FOOD SOURCE9A Canned food product observed dented and not segregated from other consumable food items. 2 3 4 5 –9B Thawing procedures improper. 2 3 4 5 –9C Food contact surface not properly maintained. 2 3 4 5 –

FACILITY MAINTENANCE10A Toilet facility not maintained and provided with toilet paper, waste receptacle and self-closing door. 2 3 4 5 –10B Plumbing not properly installed or maintained; anti-siphonage or backflow prevention device not provided where required; equipment

or floor not properly drained; sewage disposal system in disrepair or not functioning properly. 2 3 4 5 28

10C Lighting inadequate; permanent lighting not provided in food preparation areas, ware washing areas, and storage rooms. 2 3 4 5 –10D Mechanical or natural ventilation system not provided, improperly installed, in disrepair and/or fails to prevent excessive build-up of grease, heat, steam

condensation vapors, odors, smoke and fumes. 2 3 4 5 –

10E Accurate thermometer not provided in refrigerated or hot holding equipment. 2 3 4 5 –10F Non-food contact surface improperly constructed. Unacceptable material used. Non-food contact surface or equipment improperly maintained

and/or not properly sealed, raised, spaced or movable to allow accessibility for cleaning on all sides, above and underneath the unit. 2 3 4 5 –

10G Food service operation occurring in room used as living or sleeping quarters. 2 3 4 5 –10H Proper sanitization not provided for utensil ware washing operation. 2 3 4 5 –10I Single service item reused, improperly stored, dispensed; not used when required. 2 3 4 5 –10J “Wash hands” sign not posted at hand-wash facility. 2

OTHER GENERALS99B Other general. 2 3 4 5 28

GENERAL VIOLATIONS TOTAL:

CRITICAL AND GENERAL COMBINED TOTAL:

PART TWO – UNSCORED VIOLATIONS

CONDITION OBSERVEDYES NO

DISTRIBUTION OF TOBACCO PRODUCTS THROUGH VENDING MACHINES

15A Tobacco vending machine present where prohibited.

15B Tobacco vending machine placed less than 25 feet from entrance to premises.

15C Tobacco vending machine not visible to the operator, employee or agent.

15D Durable sign with license number, expiration date, address and phone number not posted.

TOBACCO PRODUCT REGULATION ACT

15E Out-of-package sale of tobacco products observed.

15F Employee under the age of 18 selling tobacco product without direct supervision of an adult retail dealer or dealer.

15G Sale of cigarettes, tobacco products, liquid nicotine or electronic cigarettes to persons under age 21 observed.

15H Sign prohibiting sale of tobacco products/electronic cigarettes to persons under age 21 not conspicuously posted.

15HH Sign prohibiting sale of non-tobacco shisha, pipes, or rolling papers to persons under age 18 not conspicuously posted.

15I Cigars that cost more than $3 each not sold in packages of four or more.

15J Little cigars sold individually or in packages that contain less than twenty little cigars.

15K “Sale of Cigarettes” tax stamp sign not posted.

15L Sale of cigarettes without tax stamp.

15M Sale of non-tobacco shisha, pipes or rolling papers to individuals under 18 years of age observed.

REGULATING TOBACCO SALES

15N Sale of cigarettes and little cigars at less than the floor price.

15O Sale of cigars and cigarettes at less than the listed price.

15P Sale of tobacco products at less than the listed price.

15Q Distributing tobacco at less than basic cost to the public or at a public event.

* Public Health Hazards (PHH) must be corrected immediately + Pre-permit Serious (PPS) Violations that must be corrected before permit is issued

Michael R. BloombergMayor

Thomas Farley, M.D., M.P.H.Commissioner

YES NO

SMOKE-FREE AIR ACT

15R “No Smoking or Using Electronic Cigarettes” sign not conspicuously posted. Health warning not present on “Smoking Permitted” sign.

15S “Smoking or Using Electronic Cigarettes Permitted” sign not conspicuously posted. Health warning not present on “Smoking Permitted” sign.

15T“Smoking is Prohibited in All Areas of this Hotel (Motel), Except in Guest Rooms Designated as Smoking Rooms. Please Extinguish Your Cigarette, Cigar or Pipe, or Electronic Cigarette” sign not conspicuously posted. Health warning not present on “Smoking Permitted” sign.

15U Size of the lettering of the “Smoking Permitted And Electronic Cigarette Use Permitted” sign exceeds that of the “No Smoking/No Electronic Cigarette Use” sign.

15V “No Smoking/No Electronic Cigarette Usage” message not shown on motion picture screen.

15W Ashtrays in smoke-free area(s).

15XOperator failed to make good faith effort to inform smokers of the Smoke-Free Air Act prohibition of smoking or using electronic cigarettes. Smoking permitted in an area where it is prohibited.

15Y Smoking use permitted and/or allowed in smoking prohibited areas under the control of the operator.

15Z Smoking and electronic cigarette use workplace policy inadequate, not posted or not provided to employees.

15AA Use of tobacco product on school premises (at or below the 12th-grade level) observed.

15AB Failure to register retail tobacco or electronic cigarette store.

SALE OF HERBAL CIGARETTES, TOBACCO HEALTH WARNING AND SMOKING CESSATION

15AC Sale of herbal cigarettes to minors observed.

RESTRICTION ON THE SALE OF CERTAIN FLAVORED TOBACCO

15AD A flavored tobacco product sold or offered for sale in an establishment other than a tobacco bar.

15AE Original label for tobacco or non-tobacco products for smoking sold or offered for sale not maintained on site.

ARTIFICIAL TRANS FAT

16A A food containing artificial trans fat, with 0.5 grams or more of trans fat per serving, is being stored, distributed, held for service, used in preparation of a menu item or served.

16BThe original nutritional fact labels and/or ingredient label for a cooking oil, shortening or margarine or food item sold in bulk or acceptable manufacturer’s documentation not maintained on site.

CALORIE MENU LABELING

16CCaloric content not posted on menus, menu boards or food tags, in a food service establishment that is 1 of 15 or more outlets operating the same type of business nationally under common ownership or control, or as a franchise or doing business under the same name, for each menu item that is served in portions, the size and content of which are standardized.

16ECaloric content range (minimum to maximum) not posted on menus and or menu boards for each flavor, variety and size of each menu item that is offered for sale in different flavors, varieties and sizes.

16FSpecific caloric content or range thereof not posted on menus, menu boards or food tags for each menu item offered as a combination meal with multiple options that are listed as single items.

SODIUM MENU LABELING

16J

Sodium warning icon not posted on menus, menu boards or food tags for food items that contain 2,300 mg or more of sodium in a food service establishment that is 1 of 15 or more outlets operating the same type of business nationally under common ownership or control, or as a franchise or doing business under the same name, for each menu item that is served in portions, the size and content of which are standardized.

16KSodium warning icon posted on menus, menu boards or food tags for food items that contain 2,300 mg or more of sodium is not a black and white equilateral triangle; and/or the equilateral triangle is not as wide as it is tall, and/or is not equal in height to the largest letter in the food item’s name, as displayed on the menu, menu board or tag.

16LSodium warning statement not posted conspicuously at the point of purchase. “Warning: [icon image] indicates that the sodium (salt) content of this item is higher than the total daily recommended limit (2,300 mg). High sodium intake can increase blood pressure and risk of heart disease and stroke.”

ADMINISTRATION AND DOCUMENTATION

18A Current valid permit, registration or other authorization to operate establishment not available.

18B Document issued by the Board of Health, Commissioner or Department unlawfully reproduced or altered.

18C Notice of the Department or Board of Health mutilated, obstructed or removed.

18D Failure to comply with an Order of the Board of Health, Commissioner or Department.

18E Failure to report occurrences of suspected food-borne illness to the Department.

18F Permit not conspicuously displayed.

18G Food Protection Certificate not available for Department inspection.

18HFailure of event sponsor to exclude vendor without a current valid permit or registration. Operator of shared kitchen allowed unpermitted caterer or other user; or failed to provide copy of agreement between operator and user.

18I Failure to produce pest management contract; failure to keep records showing existence of contract at establishment.

18J Unapproved outdoor, street or sidewalk cooking.

SIGNAGE

20A Food allergy information poster not conspicuously posted where food is being prepared or processed by food workers.

20B Food allergy information poster not posted in language understood by all food workers.

20C Food allergy poster does not contain text provided or approved by Department.

20D“Choking first aid” poster not posted. “Alcohol and pregnancy” warning sign not posted. “Resuscitation equipment: exhaled air resuscitation masks (adult & pediatric), latex gloves” sign not posted.

20E Letter grade or “Grade Pending” card not conspicuously posted and visible to passersby.

20F Current letter grade or “Grade Pending” card not posted.

20G Food Protection Certificate not available for inspection.

NUISANCE AND MISCELLANEOUS

22A Nuisance created or allowed to exist. Facility not free from unsafe, hazardous, offensive or annoying conditions.

22C Bulb not shielded or shatterproof, and/or endcaps or other devices not provided in areas where there is extreme heat, temperature changes, or where accidental contact may occur.

22D Plastic containers with microwave safe markings not used for heating food.

22E ROP processing equipment not approved by the Department.

22F Misbranded, mislabeled packaged food products.

Bureau of Food Safety and Community SanitationSELF-INSPECTION WORKSHEET FOR FOOD SERVICE ESTABLISHMENTS cont.

* Public Health Hazards (PHH) must be corrected immediately + Pre-permit Serious (PPS) Violations that must be corrected before permit is issued

Bureau of Food Safety and Community Sanitation Contact InformationPhone: 212-676-1600 Fax: 212-676-1666 Web: nyc.gov/health

Michael R. BloombergMayor

Thomas Farley, M.D., M.P.H.Commissioner

Mic

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Thom

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CONDITION OBSERVED

Self-Inspection

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June 2

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