HomeMy WebLinkAboutMinnesota Food Inspection Report 10/22/03 Ei I N N E S O T AMinnesota Department of Health
millEnvironmental Health Division-Environmental Health Services
Metro Square Building,Suite 220,P.O.Box 64975
St.Paul,Minnesota 55164-0975
DEPANTEIENTAENIALTH 651/215-0870 Page of
MINNESOTA FOOD CODE INSPECTION WORKSHEET Date
License#:
Establishment Name
County: City/Township:
Code Critical The following item(s) are issued to assist you in complying with the Minnesota Food
Reference (X) Code and must be corrected by the date indicated.
Report Received By: Title:
Inspector: _Telephone:
IC#140-0043 3/99
INTERAGENCY REQUEST for INSPECTION ' Return to address
on next page
To°
( .State/Local Health Inspector
(-tocal Building Inspector
(A-State/Local Fire Inspector
Date:
1 —
From: /3 qtr t-✓ _.'</-0 '-,"1%- � f icensor) Phone number: G Sl -2y d' 6 3/4
Prior to issuing a license, verification is required that a facility is in compliance with appropriate
state or local codes for health, building, and fire. Please complete the applicable section and
return to the Department of Human Services, Division of Licensing with any orders attached. A
copy of the orders should also be provided to the program.
Name of Facility: .h7 ,4ef d'S HOCk, A5e roposed use: C . lir`,,,-'„i.
Name of Program: 5)) e Aeid Of Me /-4e 1..141-A€4-40.7 eK1',,4
Address: / 3746 i "lc/)e,,44- A • Yr%d/' lomat, AIA/ x337 _ .
Street City Zip Code
Program contact person: ,4//Ge 41 elf/ CJ) Phone: 152, y4/7 2970
Area to be used: Numbers/Age Ranges of Participants: Facility plans
Basement ( ) 6 weeks to 16 months: to serve
First floor (/1 16 months to 33 mos.: / handicapped:
Second ( ) 33 mos. to kindergarten: Yes (;.-)''
Other ( ) kindergarten to 12 years: No ( )
Specify: Total: C)
Health Request: ( ) Licensed ( ) Not Licensed ( ) Application left or mailed
( ) No orders necessary at time of inspection ( ) Major orders issued
( ) Minor orders issued ( ) Major revisions needed before license can be issued
Signature: Date:
Building Code Request: ( ) Not applicable: facility located in non-coded area
Date referendum vote removing code requirements:
Signature and Title of Local Official:
An inspection is required for all proposed facilities located in a code area which involves new
construction, major renovation or change in occupancy, (i.e. any facility not currently used for the
proposed usage).
(Facility meets requirements
♦ Continued on next page
.
Page 2
Building Code Request ( continued)
( ) Facility does not meet requirements and cannot be occupied until orders are met
( ) Facility does not meet requirements, but may temporarily be occupied until
(date), pending completion of orders.
Signature of Building Code Inspector: . ,ALl_ -;Allr-
Certificate Number: I,°LS L Date: IDG 114` 53
Fire Code Request: A fire inspection is required for all proposed facilities. Facilities
located in an area of the state under the Uniform Building Code must meet applicable fire code
requirements. (If both codes address a specific area, the UBC takes precedence over the fire
code). Facilities located in an area of the state not under the Uniform Building Code must meet
applicable fire code requirements. In either instance, the Minnesota Uniform Fire Code applies.
(/Facility meets requirements of the fire code
( ) Facility does not meet requirements of the fire code and cannot be occupied
until orders are met
( ) Facility does not meet requirements, but may temporarily be occupied until
(date), pending completion of orders.
Signature of Fire Inspector: �� Date: G bl/
y4 /03
Comments:
Mail or Fax to: Minnesota Department of Human Services
Division of Licensing
444 Lafayette Road
St. Paul, MN 55155-3842
Fax number: (651) 297-1490