S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DENNY'S #377 812-482-6006

3850 NEWTON STREET, JASPER, IN, 47546 812-482-321205/16/2018

55

SERVUS, INC. ✔ Yes 05/26/2018

4201 MANNHEIM RD., STE. A, JASPER, IN, 47546

Crystal Larrison6 6 3

Crystal Larrison exp. 4/20/2022

345 C R 4 of 5 hand wash sinks contained items indicating being used for things other than hand washing 05/16/2018,05/16/2018

187 C Pull out fridge in middle of line both drawers found to have cooked and raw meats measured to be from 49-51 05/16/2018Cheese at start of line measured to be 50 degrees 05/16/2018

Sausage under the grill measured to be approximately 47 degrees 05/16/2018173 C Raw chicken stored directly next to raw beef 05/16/2018

Cooked meat stored next to raw beef 05/16/2018129 C Observed employee applying gloves without previously washing hands 05/16/2018200 C Observed serving utensils being stored in containers containing old food debris on dry storage rack 05/16/2018

Observed clean plates on serving line containing food particles 05/16/2018296 C R Front line food prep equipment contained moderate amounts of food debris 05/16/2018295 NC R Shelving units on serving line contained food debris and particles 05/16/2018

Walls, hood, and microwave contained debris. Reach in cooler contained contaminated standing water 05/16/2018431 NC Air vents, floors, walls, ceilings contain food particles and debris build up 05/23/2018

Clutter observed in dry storage near the soda machine 05/23/2018245 NC 3 towels used to wipe food and non food contact surfaces observed not being stored in sanitizer solution 05/16/2018256 NC Cooks on front line were without food thermometers 05/16/2018177 NC Two boxes of packaged foods found on floor in the freezer unit 05/16/2018

Beth Johnson Kylie Shephard

NARRATIVE REPORT

Establishment Name Address Inspection Date

Item # C/NC R REMARKS TO BE CORRECTED BY

Received By (Name & Title) Inspected By (Name & Title) Page___of ___

DENNY'S #377 3850 NEWTON STREET, JASPER, IN, 47546 05/16/2018

433 NC One wet mop found lying directly on floor, second mop was in contact with bucket

Beth Johnson Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CVS PHARMACY #6881 (HUNTINGBURG) 812-683-3309

610 N MAIN STREET, HUNTINGBURG, IN, 47542 401-770-281605/17/2018

51

HOOK - SUPERX, LLC. ✔ 05/27/2018

ONE CVS DRIVE, MAIL CODE #1160, WOONSOCKET, RI, 02895

ANTHONY CASTELLO0 0 0

Exempt

No violations observed at time of inspection

Derrick Brang Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DOLLAR GENERAL STORE #2144 812-817-0005

1710 N MAIN STREET, HUNTINGBURG, IN, 47542 615-855-400005/17/2018

56

DOLGENCORP, LLC. ✔ 05/27/2018

100 MISSION RIDGE, GOODLETTSVILLE, TN, 37072

DOLGENCORP, LLC.1 1 2

Exempt

144 C R Observed multiple severely dented cans in the canned good area 05/17/2018433 NC R Mop was observed not being hung to dry 05/17/2018

Terri Howe Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

RED HOUSE 812-309-2139

1100 N. Main, Huntingburg, IN, 47542 812-309-213905/21/2018

253

JACK & DENISE MORGAN 05/31/2018

502 E. 1st Ave., Huntingburg, IN, 47541✔JACK & DENISE MORGAN

0 0 0

Exempt

No violations observed at time of inspection.Ok to operate

Denise Morgan Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DOROTHEA DIX HOME (SOUTHERN HILLS) 812-683-2419

1002 E 10TH STREET, HUNTINGBURG, IN, 47542 812-482-302005/21/2018

62

E. Joseph Kimmel, Jr. ✔ 05/31/2018

P.O. BOX 769, JASPER, IN, 47547-0769

Aaron Merkel0 0 0

Jeana Bateman (Mathers) exp 11/12/2018

No violations at time of inspection

Aaron Merkel Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

FAMILY DOLLAR #29125 812-817-3015

705 N MAIN STREET, HUNTINGBURG, IN, 47542 757-321-500005/21/2018

70

FAMILY DOLLAR STORES OF IN, LLC ✔ 05/31/2018

500 VOLVO PARKWAY, CHESAPEAKE, VA, 23320

FAMILY DOLLAR STORES OF IN, LLC1 3 0

Exempt

144 C Multiple cans found to be dented in the canned goods aisle 05/21/2018433 NC Mop found not being hung to dry 05/21/2018431 NC Underneath of aisle shelving contains large amounts of debris, dirt, and food items 05/22/2018351 NC Bathroom used by females did not have a covered receptacle 05/21/2018

Ginger Black Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

LONG JOHN SILVER'S #70196 812-482-2132

3960 N. NEWTON STREET, JASPER, IN, 47546 502-815-611405/21/2018

128

LJS OPCO ONE LLC ✔ 05/31/2018

10350 Ormsby Park Pl, Louisville, KY, 40222

David Chapman1 1 0

Vicky Hagan exp. 2/23/2021

295 C Vents throughout establishment showed dirt accumulation 05/28/2018Behind fryers showed significant grease accumulation 05/28/2018

Underneath of front serving counters showed large amount of food debris 05/28/2018Tiles in front of fryer show severe damage and cracking 06/04/2018

Refrigerator/freezer near fryer had very rusted/dirty holding racks 05/28/2018297 NC Observed mold buildup on front and back ice maker 05/21/2018

Vicky Hagan Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

J & S SCHMITT FARMS 812-631-2037

3295 GRASSLAND HILLS RD, JASPER, IN, 47546 812-631-203705/22/2018

109

KRISTIN BRAUN ✔ 06/01/2018

3295 GRASSLAND HILLS RD., JASPER, IN, 47546

KRISTIN BRAUN0 0 0

Kristin Braun exp. 12/31/17

No violations at time of inspection

Kristin Braun Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CHRISTIAN MINISTRIES OF HUNTINGBURG, INC. 812-683-5490

321 E 4TH STREET, HUNTINGBURG, IN, 47542 812-683-549005/22/2018

220

CHRISTIAN MINISTRIES OF HUNTINGBURG INC. ✔ 06/01/2018

JOHN TRETTER0 0 0

exempt

No Violations at this time

John Tretter Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

RED ROOF INN & SUITES 812-367-1122

440 S MAIN STREET, FERDINAND, IN, 47532 323-691-451305/23/2018

164

KRISHNA 2006 INC. ✔ 06/02/2018

2239 LUCKENBACH LANE, IRVING, TX, 75063

Ami Patel/Ronnie Patel0 1 0

Bunty Patel exp. 7/21/2020

256 NC No temperature measuring device in small refrigerator near microwave 05/25/2018

Brenden Woodruff Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

TACO BELL #3001094 (Ferdinand) 812-367-0817

420 S MAIN STREET, FERDINAND, IN, 47532 503-722-282505/23/2018

195

BELL INDIANA, LLC ✔ 06/02/2018

PO BOX 507, WEST LINN, OR, 97068

BELL INDIANA, LLC0 2 0

Rhonda King 7/21/22

297 NC Drive thru soda station has heavy soda buildup. Underneath racks in facility has food and trash debris 05/25/2018295 NC Food preparation line has food debris buildup 05/24/2018

Rhonda King Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CVS PHARMACY #6871 (FERDINAND) 812-367-2030

20 INDUSTRIAL PARK DRIVE, FERDINAND, IN, 47532 401-770-281605/23/2018

49

HOOK - SUPERX, LLC. ✔ 06/02/2018

ONE CVS DRIVE, MAIL CODE #1160, WOONSOCKET, RI, 02895

Jennifer Pagragan1 0 0

Exempt

296 C Significant mold buildup on ceiling, racks, etc in all freezer/refrigerator units in the facility. 05/23/2018

Lisa Barnett Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DOLLAR GENERAL STORE #7817 812-817-0006

131 E 10TH STREET, FERDINAND, IN, 47532 615-855-400005/23/2018

59

DOLGENCORP, LLC. ✔ 06/02/2018

100 MISSION RIDGE, GOODLETTSVILLE, TN, 37072

DOLGENCORP, LLC.2 1 1

Exempt

144 C Multiple severely damaged cans found in canned food aisles 05/23/2018416 NC R Dead bugs found in drink cooler near check out and ice cream freezer near entrance 05/23/2018415 C Excessive live bugs found in ice cream freezer at front of store 05/23/2018

Gail Gentry Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

SISTERS OF SAINT BENEDICT 812-367-1411

802 E 10TH STREET, FERDINAND, IN, 47546 812-367-141105/23/2018

246

SISTERS OF ST. BENEDICT ✔ 06/02/2018

802 E 10TH STREET, FERDINAND, IN, 47532

Kris Lasher0 0 0

Erin Riley exp. 9/24/2019

No violations observed at time of inspection

Kris Lasher Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

SOUTHERN INDIANA BUTCHER SUPPLY 812-998-2277

131 E. 10TH STREET, FERDINAND, IN, 47532 812-998-227705/23/2018

178

JESSE SUMMERS ✔ 06/02/2018

P.O. BOX 34, LAMAR, IN, 47550

JESSE SUMMERS0 0 0

Jesse Summers exp. 3/13/2022

No violations observed at time of inspection

Jesse Summers Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

WENDY'S #340 812-367-0594

480 S. MAIN STREET, FERDINAND, IN, 47532 812-482-321205/23/2018

209

SERVUS, INC. ✔ 06/02/2018

4201 MANNHEIM RD., STE. A, JASPER, IN, 47546

Jessica Weger2 6 2

Rhonda White exp 4/11/2023

187 C R Hamburger patty refrigeration unit observed to be between 47-51 degrees 05/23/2018Refrigeration unit closest to fryers not holding temp. Items measured at approx. 50 degrees 05/23/2018

128 C R Hand wash sink in front of establishment not reaching 100 degrees 05/30/2018433 NC Two mops observed to be drying on the floor 05/23/2018146 NC Tomatoes and other items in walk in cooler not labeled with date 05/23/2018138 NC Employee observed not wearing hair restraint in food preparation area 05/23/2018295 NC Food establishment showed general overall buildup of food debris and grease 05/30/2018218 NC Seals on multiple refrigeration units appeared to be ripped 05/30/2018177 NC Soft serve in walk in cooler possibly being exposed to contamination via raw hamburger patties 05/23/2018

Lettuce in walk in cooler has potential of being contaminated by soft serve due to how it is being stored 05/23/2018

Rhonda White Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

JASPER DOG HAUS INC 812-309-4672

155 2ND STREET, JASPER, IN, 47546 812-309-467205/23/2018

300

DOUG WATSON 06/02/2018

155 2ND STREET, JASPER, IN, 47546✔DOUG WATSON

0 0 0

DOUG WATSON

OK TO OPERATE

Doug Watson Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DEB'S TRUCK STOP 812-389-2290

502 W HWY 64, BIRDSEYE, IN, 47513 812-639-752605/24/2018

54

DEBORAH D ERNST 06/03/2018✔

25150 CHANDLER RD, BRISTOW, IN, 47515

DEBORAH D ERNST7 8 10

DEBORAH ERNST EXP. 7/9/2019

295 C R Significant grease and food buildup on non food contact surfaces throughout establishment 08/15/2018415 C R Dead pests found in kitchen area 05/24/2018177 C R Observed single use food items being stored directly on floor (Cups, potatoes, etc) 05/24/2018173 C R Raw food items (hamburger patties, chicken, bacon) being stored above ready to eat food items in all refrigeration units 05/24/2018171 C R Observed bare hand contact with food items 05/24/2018188 C R Food items stored in refrigeration units did not have a cover 05/24/2018296 NC R Refrigeration unit handles, drawer handles,inside refrigeration units need to be cleaned 05/24/2018174 NC R Foods in cooler were not date marked or labeled 05/24/2018129 C Observed improper hand washing procedures, hand wash sink being used for dishes and food prep 05/24/2018218 NC R Sandwich prep table and dish washing unit not functioning as intended 08/15/2018231 NC R Can opener soiled with food debris and metal shards (needs sharpened) 05/24/2018256 NC Refrigeration units were not all equipped with thermometers, or thermometers are not working properly 05/25/2018232 NC Integrity of counter tops, ceilings, and floors is compromised through chipping 08/15/2018433 NC Mop was not being hung to dry 05/24/2018355 NC Establishment does not have a service sink, mop water being discarded of outside 05/31/2018

Deb Ernst Kylie Shephard

Dubois County Health Department

1187 S St Charles StJasper, Indiana 47546

Phone: (812) 481-7050E-mail: dchealth@duboiscountyin.gov

Web Page: duboiscountyin.org/offices/health.html

Pool Name Telephone Number Date of Inspection (mm/dd/yy)

Establishment Address (number and street, city, state, zip code) Purpose:

Routine Follow-up Complaint Pre-operational Closure

Reason for closure:

Disinfectant Equipment Fecal Cyanuric acid Hand feeding VGBA Spa temperature Cloudy Other: pH

_______________

Responsible Person’s E-mail

Pool Volume (gallons) Follow-up

Indoor Outdoor Wading Pool SpaWater Chemistry as Tested

Main Pool Wading Pool Spa Cl/Br ppm Cl/Br ppm Cl/Br ________ppm pH pH pH __________ TA ppm TA ppm TA __________ppm CYA ppm CYA ppm Spa ºF

VF: Violation found NV: No violation C: Corrected onsite NA: Not applicable NO: Not observed

VF NV C NA NO

1. WATER QUALITY

a. Residual disinfectant levels below minimum required

b. Residual disinfectant levels above maximum allowed

c. pH outside acceptable range of 7.2-7.8

d. pH outside allowable range of 6.8-8.0

e. Alkalinity outside acceptable range of 80-120 ppm

f. Cyanuric acid (stabilizer) level exceeds maximum allowed (60 ppm)

g. Spa water temperature exceeds maximum allowed (104°F)

h. Pool open within 1 hour after manual addition of chemicals

2. DISINFECTION, CIRCULATION AND FILTRATION

a. Disinfection is not continuous and automatic (see comments section)

b. Main drain and/or pool bottom is not visible from pool deck

c. Pump, filter or disinfectant feeder not operational or malfunctioning

d. Water level does not allow for adequate skimming effect

e. Flow meter missing or not operational

f. Skimmer weir(s) or basket(s) missing or damaged

g. Broken, missing or inadequate main drain grate(s)

h. Required anti-entrapment devices missing or not operational

3. TESTING AND RECORD KEEPING

a. Missing or unapproved test kit

b. Pool or spa is not being tested as required

c. Log book not maintained and/or available for review

4. POOL AND CHEMICAL SAFETY

a. Qualified lifeguard not on duty at pool side when required

b. Lifeguard performing other duties while on surveillance duty

c. Missing or inadequate flotation device

d. Missing or inadequate reach pole

e. Missing or inadequate spine board with head immobilizer

f. Missing or inadequate first aid kit

g. Missing emergency phone

h. No buoyed safety line where pool exceeds 5 feet in depth

i. Improperly stored chemicals

POOL-SUPER 8 812-827-2764 05/24/2018

75 INDIANA ST, JASPER, IN, 47546

Dean Wigand

3.57.075

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

VF NV C NA NO

5. SIGNS, ENCLOSURES, & SANITATION

a. Missing or inadequate pool warning sign (see comments section)

b. Visible dirt or debris on the pool or spa bottom and/or walls

c. Scum, oils or floating matter on pool or spa surfaces

d. Trash or debris on deck and/or floor of pool or spa area

e. Equipment room not in a safe and sanitary condition

f. Missing or inadequate self-closing latch on gate or door

6. OTHER VIOLATIONS AND ADDITIONAL COMMENTS

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Devin Bledsoe Kylie Shephard

✔

✔

✔

✔

✔

✔

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CASH SAVER #1174 812-482-2366

3605 N. NEWTON STREET, JASPER, IN, 47546 812-634-702905/25/2018

171

BUEHLER LLC. ✔ 06/04/2018

307 NEWTON STREET, JASPER, IN, 47546

BRANDEN BOHALL1 5 0

BARBARA KENDALL 1/22/20

144 C Several dented found through out the store Corrected177 NC Pastry items stored on floor by produce also multiple items being stored in the walkin freezer located in the back storage area of store 05/31/2018218 NC 4 door ice cream freezer producing heavy ice build up, asst. manager told me the seals on the doors need to be replaced and someone will be taking care of that soon Corrected422 NC Employee food being stored in walk in produce needs to be labeled to identify that it is employee food only 05/31/2018342 NC Both employee bathrooms hand washing sinks have a hot water temp of 94 notified asst. manager that the hot water needs to be at least 100 degrees 05/31/2018351 NC Womens room trash can is missing a lid 05/31/2018

Bailey Holt Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CHOCOLATE BLISS 812-482-1617

110 E 5th STREET, JASPER, IN, 47546 812-631-019005/25/2018

32

ANN KNIES ✔ 06/04/2018

338 DAISY LANE, JASPER, IN, 47546

ANN KNIES0 0 0

Ann Knies exp. 5/5/2021

No violations at this time

Ann Knies Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CLIFFORD BIERS HOME 812-482-3503

140 E 37TH STREET, JASPER, IN, 47546 812-482-302005/25/2018

46

E. Joseph Kimmel, Jr. ✔ 06/04/2018

P.O. BOX 769, JASPER, IN, 47547

Kirstie Backer0 0 0

Jeana Bateman (Mathers) exp. 11/12/2018

No violations at this time

Kirstie Backer Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

COLUMBIAN HOME ASSOCIATION (KNIGHTS OF COLUMBUS) 812-482-4292

201 E 30th STREET, JASPER, IN, 47546 812-482-429205/25/2018

118

MEMBERS OF THE CLUB ✔ 06/04/2018

201 E 30TH STREET, JASPER, IN, 47546

Gary Knust, Office Manager0 1 0

Patricia Kiefer exp. 6/6/2021

410 NC Light bulb shield missing from walk in freezer 06/04/2018

Anita Ackerman Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

CVS PHARMACY #6878 (JASPER) 812-482-3300

617 WEST 6TH STREET, JASPER, IN, 47546 401-770-281605/25/2018

50

HOOK - SUPERX, LLC. 06/04/2018

ONE CVS DRIVE, MAIL CODE #1160, WOONSOCKET, RI, 02895

Angela Bauer0 1 0

Exempt

256 NC thermometers missing from 3 double door fridges(soda,sport drinks,water) 05/31/2018

Susan Gilliam Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

DOLLAR GENERAL STORE #4509 812-634-6485

4117 N MANNHEIM RD., JASPER, IN, 47546 615-855-400005/25/2018

58

DOLGENCORP, LLC. ✔ 06/04/2018

100 MISSION RIDGE, GOODLETTSVILLE, TN, 37072

DOLGENCORP, LLC.0 3 0

Exempt

351 NC unisex bathroom is missing a lid Corrected433 NC both mops need to be able to hang dry Corrected256 NC single door fridge is missing thermometer 05/31/2018

Talaisha Smith Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

OLD SCHOOL CAFÉ-LEAGUE STADIUM

203 S CHERRY ST. , HUNTINGBURG, IN, 47542 812-661-263505/25/2018

252

BOB AND SANDRA AHLEMEIER 06/04/2018

✔BOB AND SANDRA AHLEMEIER0 0 0

SANDRA AHLEMEIER

OK TO OPERATE

BOB AHLEMEIER Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

HUNTINGBURG COUNTRY CLUB INC. 812-683-3376

739 W THIRD STREET, HUNTINGBURG, IN, 47542 812-683-337605/25/2018

107

MEMBERS OF CLUB ✔ 06/04/2018

739 W. THIRD STREET, HUNTINGBURG, IN, 47542

PHIL OHANIAN0 1 0

Phil Ohanian exp NONE GIVEN

146 NC Meat in freezer not labeled properly 05/25/2018

Phil Ohanian Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

HOMETOWN IGA #460 812-683-4653

312 E 12TH STREET, HUNTINGBURG, IN, 47542 812-482-136605/25/2018

99

HOUCHENS NORTH FOODS LLC ✔ 06/04/2018

611 BARTLEY STREET, JASPER, IN, 47546

Jeremy Thyen4 2 0

Jeremy Thyen exp. 3/30/2021

187 C Items in salad bar not being held at proper temperature (cheese, cottage cheese, etc) Observed items being help at approx. 50 degrees Corrected295 NC Food contact and non contact surfaces soiled with debris and food particles. Observed this in deli, walk in coolers, etc 06/01/2018144 C Multiple cans found to be dented in the canned food area 05/25/2018347 NC Hand wash sinks in deli and meat area did not have paper towels for the hand wash sink 05/25/2018177 C Raw meat in food cooler not covered 05/25/2018

Food items found being stored on floor of walk in cooler 05/25/2018173 C Contaminated knife being stored on boxes with food in meat cooler 05/25/2018

Jeremy Thyen Kylie Shephard

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

FERDINAND FOOD PRODUCTION 812-367-2990

313 W 9TH STREET, FERDINAND, IN, 47532 812-367-228005/29/2018

74

Town of Ferdinand ✔ 06/08/2018

2065 Main Street, FERDINAND, IN, 47532

ROBIN WINKLER0 0 0

Marla Burger exp. 9/12/2022

No violations at time of inspection

Robin Winkler Kylie Shephard

Dubois County Health Department

1187 S St Charles StJasper, Indiana 47546

Phone: (812) 481-7050E-mail: dchealth@duboiscountyin.gov

Web Page: duboiscountyin.org/offices/health.html

Pool Name Telephone Number Date of Inspection (mm/dd/yy)

Establishment Address (number and street, city, state, zip code) Purpose:

Routine Follow-up Complaint Pre-operational Closure

Reason for closure:

Disinfectant Equipment Fecal Cyanuric acid Hand feeding VGBA Spa temperature Cloudy Other: pH

_______________

Responsible Person’s E-mail

Pool Volume (gallons) Follow-up

Indoor Outdoor Wading Pool SpaWater Chemistry as Tested

Main Pool Wading Pool Spa Cl/Br ppm Cl/Br ppm Cl/Br ________ppm pH pH pH __________ TA ppm TA ppm TA __________ppm CYA ppm CYA ppm Spa ºF

VF: Violation found NV: No violation C: Corrected onsite NA: Not applicable NO: Not observed

VF NV C NA NO

1. WATER QUALITY

a. Residual disinfectant levels below minimum required

b. Residual disinfectant levels above maximum allowed

c. pH outside acceptable range of 7.2-7.8

d. pH outside allowable range of 6.8-8.0

e. Alkalinity outside acceptable range of 80-120 ppm

f. Cyanuric acid (stabilizer) level exceeds maximum allowed (60 ppm)

g. Spa water temperature exceeds maximum allowed (104°F)

h. Pool open within 1 hour after manual addition of chemicals

2. DISINFECTION, CIRCULATION AND FILTRATION

a. Disinfection is not continuous and automatic (see comments section)

b. Main drain and/or pool bottom is not visible from pool deck

c. Pump, filter or disinfectant feeder not operational or malfunctioning

d. Water level does not allow for adequate skimming effect

e. Flow meter missing or not operational

f. Skimmer weir(s) or basket(s) missing or damaged

g. Broken, missing or inadequate main drain grate(s)

h. Required anti-entrapment devices missing or not operational

3. TESTING AND RECORD KEEPING

a. Missing or unapproved test kit

b. Pool or spa is not being tested as required

c. Log book not maintained and/or available for review

4. POOL AND CHEMICAL SAFETY

a. Qualified lifeguard not on duty at pool side when required

b. Lifeguard performing other duties while on surveillance duty

c. Missing or inadequate flotation device

d. Missing or inadequate reach pole

e. Missing or inadequate spine board with head immobilizer

f. Missing or inadequate first aid kit

g. Missing emergency phone

h. No buoyed safety line where pool exceeds 5 feet in depth

i. Improperly stored chemicals

POOL-DAYS INN OF JASPER 812-482-6000 05/29/2018

272 BRUCKE STRASSE, JASPER, IN, 47546

DEAN WIGAND 482-3292

27.2100

0

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

VF NV C NA NO

5. SIGNS, ENCLOSURES, & SANITATION

a. Missing or inadequate pool warning sign (see comments section)

b. Visible dirt or debris on the pool or spa bottom and/or walls

c. Scum, oils or floating matter on pool or spa surfaces

d. Trash or debris on deck and/or floor of pool or spa area

e. Equipment room not in a safe and sanitary condition

f. Missing or inadequate self-closing latch on gate or door

6. OTHER VIOLATIONS AND ADDITIONAL COMMENTS

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Combined chlorine is above 0.5 ppm. Pool needs to be shocked

jamie sorrells Shawn D. Werner

✔

✔

✔

✔

✔

✔

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

McDONALD'S #575810 (Ferdinand) 812-998-2023

25 INDUSTRIAL PARK ROAD, FERDINAND, IN, 47532 270-566-174905/29/2018

139

SUSAN & RICK MANN ✔ 06/08/2018

P.O. BOX 710, JASPER, IN, 47546

DARIC HUCKELBY2 0 0

Daric Huckelby EXP 9/18/19

345 C Food items found in hand wash sink near back drive thru area Corrected303 C Sanitizer bucket did not contain actual sanitize because establishment ran out. Corrected

Angel Teague Kylie Shephard

Dubois County Health Department

1187 S St Charles StJasper, Indiana 47546

Phone: (812) 481-7050E-mail: dchealth@duboiscountyin.gov

Web Page: duboiscountyin.org/offices/health.html

Pool Name Telephone Number Date of Inspection (mm/dd/yy)

Establishment Address (number and street, city, state, zip code) Purpose:

Routine Follow-up Complaint Pre-operational Closure

Reason for closure:

Disinfectant Equipment Fecal Cyanuric acid Hand feeding VGBA Spa temperature Cloudy Other: pH

_______________

Responsible Person’s E-mail

Pool Volume (gallons) Follow-up

Indoor Outdoor Wading Pool SpaWater Chemistry as Tested

Main Pool Wading Pool Spa Cl/Br ppm Cl/Br ppm Cl/Br ________ppm pH pH pH __________ TA ppm TA ppm TA __________ppm CYA ppm CYA ppm Spa ºF

VF: Violation found NV: No violation C: Corrected onsite NA: Not applicable NO: Not observed

VF NV C NA NO

1. WATER QUALITY

a. Residual disinfectant levels below minimum required

b. Residual disinfectant levels above maximum allowed

c. pH outside acceptable range of 7.2-7.8

d. pH outside allowable range of 6.8-8.0

e. Alkalinity outside acceptable range of 80-120 ppm

f. Cyanuric acid (stabilizer) level exceeds maximum allowed (60 ppm)

g. Spa water temperature exceeds maximum allowed (104°F)

h. Pool open within 1 hour after manual addition of chemicals

2. DISINFECTION, CIRCULATION AND FILTRATION

a. Disinfection is not continuous and automatic (see comments section)

b. Main drain and/or pool bottom is not visible from pool deck

c. Pump, filter or disinfectant feeder not operational or malfunctioning

d. Water level does not allow for adequate skimming effect

e. Flow meter missing or not operational

f. Skimmer weir(s) or basket(s) missing or damaged

g. Broken, missing or inadequate main drain grate(s)

h. Required anti-entrapment devices missing or not operational

3. TESTING AND RECORD KEEPING

a. Missing or unapproved test kit

b. Pool or spa is not being tested as required

c. Log book not maintained and/or available for review

4. POOL AND CHEMICAL SAFETY

a. Qualified lifeguard not on duty at pool side when required

b. Lifeguard performing other duties while on surveillance duty

c. Missing or inadequate flotation device

d. Missing or inadequate reach pole

e. Missing or inadequate spine board with head immobilizer

f. Missing or inadequate first aid kit

g. Missing emergency phone

h. No buoyed safety line where pool exceeds 5 feet in depth

i. Improperly stored chemicals

POOL-JASPER MUNICIPAL SWIMMING POOL 812-482-1789 05/29/2018

1405 BARTLEY ST, JASPER, IN, 47546

J.P. STEMLEY

77.275

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

VF NV C NA NO

5. SIGNS, ENCLOSURES, & SANITATION

a. Missing or inadequate pool warning sign (see comments section)

b. Visible dirt or debris on the pool or spa bottom and/or walls

c. Scum, oils or floating matter on pool or spa surfaces

d. Trash or debris on deck and/or floor of pool or spa area

e. Equipment room not in a safe and sanitary condition

f. Missing or inadequate self-closing latch on gate or door

6. OTHER VIOLATIONS AND ADDITIONAL COMMENTS

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

J.P. Stemply Shawn D. Werner

✔

✔

✔

✔

✔

✔

Dubois County Health Department

1187 S St Charles StJasper, Indiana 47546

Phone: (812) 481-7050E-mail: dchealth@duboiscountyin.gov

Web Page: duboiscountyin.org/offices/health.html

Pool Name Telephone Number Date of Inspection (mm/dd/yy)

Establishment Address (number and street, city, state, zip code) Purpose:

Routine Follow-up Complaint Pre-operational Closure

Reason for closure:

Disinfectant Equipment Fecal Cyanuric acid Hand feeding VGBA Spa temperature Cloudy Other: pH

_______________

Responsible Person’s E-mail

Pool Volume (gallons) Follow-up

Indoor Outdoor Wading Pool SpaWater Chemistry as Tested

Main Pool Wading Pool Spa Cl/Br ppm Cl/Br ppm Cl/Br ________ppm pH pH pH __________ TA ppm TA ppm TA __________ppm CYA ppm CYA ppm Spa ºF

VF: Violation found NV: No violation C: Corrected onsite NA: Not applicable NO: Not observed

VF NV C NA NO

1. WATER QUALITY

a. Residual disinfectant levels below minimum required

b. Residual disinfectant levels above maximum allowed

c. pH outside acceptable range of 7.2-7.8

d. pH outside allowable range of 6.8-8.0

e. Alkalinity outside acceptable range of 80-120 ppm

f. Cyanuric acid (stabilizer) level exceeds maximum allowed (60 ppm)

g. Spa water temperature exceeds maximum allowed (104°F)

h. Pool open within 1 hour after manual addition of chemicals

2. DISINFECTION, CIRCULATION AND FILTRATION

a. Disinfection is not continuous and automatic (see comments section)

b. Main drain and/or pool bottom is not visible from pool deck

c. Pump, filter or disinfectant feeder not operational or malfunctioning

d. Water level does not allow for adequate skimming effect

e. Flow meter missing or not operational

f. Skimmer weir(s) or basket(s) missing or damaged

g. Broken, missing or inadequate main drain grate(s)

h. Required anti-entrapment devices missing or not operational

3. TESTING AND RECORD KEEPING

a. Missing or unapproved test kit

b. Pool or spa is not being tested as required

c. Log book not maintained and/or available for review

4. POOL AND CHEMICAL SAFETY

a. Qualified lifeguard not on duty at pool side when required

b. Lifeguard performing other duties while on surveillance duty

c. Missing or inadequate flotation device

d. Missing or inadequate reach pole

e. Missing or inadequate spine board with head immobilizer

f. Missing or inadequate first aid kit

g. Missing emergency phone

h. No buoyed safety line where pool exceeds 5 feet in depth

i. Improperly stored chemicals

POOL-CENTRAL GREEN INTERACTIVE FOUNTAIN 05/29/2018

370 W 6TH ST, JASPER, IN, 47546

JP STEMLEY

37.275

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

VF NV C NA NO

5. SIGNS, ENCLOSURES, & SANITATION

a. Missing or inadequate pool warning sign (see comments section)

b. Visible dirt or debris on the pool or spa bottom and/or walls

c. Scum, oils or floating matter on pool or spa surfaces

d. Trash or debris on deck and/or floor of pool or spa area

e. Equipment room not in a safe and sanitary condition

f. Missing or inadequate self-closing latch on gate or door

6. OTHER VIOLATIONS AND ADDITIONAL COMMENTS

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

J.P. Stemply Shawn D. Werner

✔

✔

✔

✔

✔

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

WALGREENS #10340 812-481-1513

3606 N. NEWTON STREET, JASPER, IN, 4754605/29/2018

206

WALGREENS COMPANY ✔ 06/08/2018

P.O. BOX 901, DEERFIELD, IL, 60015

Ralph Sims0 0 0

Exempt

No violations at this time

Ralph Sims Christina Pierini

S Retail Food Establishment Inspection Report

State Form 22116 (R7 /12-04) SDH Form 51-0001

Based on an inspection this day, the item(s) noted below identify violations of 410 IAC 7-24, Indiana Retail Food Establishment Sanitation Requirements.The time limit for correction of each violation is specified in the narrative portion of this report.

Establishment Name

Establishment Address (number and street, city, state, zip code)

Telephone Number ( ) Establishment

( ) Owner

Date of Inspection (mm/dd/yr)

ID #

Owner Follow-up Release Date

Owner’s Address

Person in Charge

Summary of Violations:

C_____ NC_____ R_____

Responsible Person’s E-mail

Certified Food Handler

Purpose:

1. Routine

2. Follow-up

3. Complaint

4. Pre-Operational

5. Temporary

6. HACCP

7. Other (list) _________________

Menu Type (See additional page)

1____2____3____4____5___

• CRITICAL ITEMS ARE IDENTIFIED IN THE CHECKLIST AND NARRATIVE COLUMNS MARKED “C”

• VIOLATION(S) REPEATED FROM PREVIOUS INSPECTIONS ARE DENOTED IN THE “SUMMARY OF VIOLATIONS” AND IN THE NARRATIVE BELOW AS “R”

Section# C/NC R Narrative To Be Corrected By

Received by (name and title printed): Inspected by (name and title printed):

Received by (signature): Inspected by (signature):

cc: cc: cc:

Dubois County Health Department

Telephone 812-481-7055Fax 812-481-7069

JASPER 8 CINEMA #319 812-634-2772

256 BRUCKE STRASSE, JASPER, IN, 47546 812-482-321205/29/2018

111

SERVUS, INC. ✔ 06/08/2018

4201 MANNHEIM RD., STE. A, JASPER, IN, 47546

Kelsey Merkel0 0 0

Brad Craig 10/12/2022

No violations at this time

Susan Sanders Christina Pierini