Free Hotel-Motel or Tourist Rooming House Inspection Report, F-47009 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-47009 (Rev. 7/09)

STATE OF WISCONSIN Bureau of Environmental and Occupational Health HFS 195, Wis. Admin. Code

HOTEL-MOTEL OR TOURIST ROOMING HOUSE INSPECTION REPORT
NAME OF ESTABLISHMENT STREET ADDRESS CITY, VILLAGE OR TOWNSHIP COUNTY

NAME OF LICENSEE

STREET ADDRESS

CITY, VILLAGE

SLEEPING ROOMS

NAME OF PREVIOUS LICENSED ESTABLISHMENT

NAME OF PREVIOUS LICENSED OPERATOR

ESTAB. PHONE NO.

I.D. NO.

SURVEY DATE FEE STATUS 1- 4 Sleeping Rooms ................. 1 5-30 Sleeping Rooms ................. 2 31-99 Sleeping Rooms ................. 3 100-199 Sleeping Rooms ............. 4 200 or More Sleeping Rooms ....... 5 Year-Round

INSPECTION STATUS Pre-Inspection ................................ 1 Pre-Inspection Follow-Up ............... 2 1st Inspection .................................. 3 Reg. Inspection .............................. 4 Follow-Up ....................................... 5 Complaint ....................................... 6 Other .............................................. 7 Summer Winter

LICENSE STATUS Release....................................1 Conditional ...............................2 Withhold ...................................3 Suspend...................................4 Operational ..............................5 Other ........................................6

RELEASE DATE INSPECTION TIME FILE NOTE

Permit Conspicuously Displayed

254.83 Rates Posted 254.73 (1) Hotel Safety (2) Emergency Assistance OPERATOR NOTE -- The violations in operating procedure or physical arrangement indicated below must be corrected by the next routine inspection or such period of time as may be specified.

HFS 195.05 WATER SUPPLY & WASTE DISPOSAL Public Water 1 _____ (2) 2 _____ (2) Public Sewer 3 _____ (3) Private Well 4 _____ (4) 1 __ X Conn 5 _____ (5) 2 __ General 6 _____ (5) (a) (b) (c) (d) Private Sewage 7 _____ (5) (e) Privies 8 _____ (6) (a) Private Fixtures 9 _____ (6) (b) 1 ___ Shared Fixtures 10 _____ (6) (b) 2 ___ Existing TRH 11 _____ (6) (c) Hot & Cold Water 12 _____ (6) (d) Soap & Towels 13 _____ (6) (e) Sex Desig. 14 _____ (7) Drinking Water 15 _____ (8) (a) Garbage Disp. 16 _____ (8) (b) Clean Cont. 17 _____ (8) (c) Garbage Cont. 18 _____ (8) (d) Rubbish Cont. HFS 195.06 FURNISHINGS, EQUIPMENT & UTENSILS 19 _____ (1) Design 20 _____ (2) Installation 21 _____ (3) 1 ___ Utensil Sanit. 22 _____ (3) 2 ___ Def. Ut. 23 _____ (4) (b) Glass Protec. Rms 24 _____ (5) Linens Furn. 25 _____ (5) 1 ___ Clean Linens 26 _____ (5) 2 ___ Sheets, Size & Fold-back 27 _____ (5) 3 ___ Soiled Linen Storage 28 _____ (5) Matt. Pad 29 _____ (6) Cleanl. of Equip & Furn.

HFS 195.07 FOOD 30 _____ (1) Food Permit 31 _____ (2) 1 ___ Ice, Source 32 _____ (2) 2 ___ Ice Mach. 33 _____ (2) 3 ___ Handling 34 _____ (2) 4 ___ Storage HFS 195.08 COMMUNICABLE DISEASE CONTROL 35 _____ Employee Health HFS 195.09 BUILDING STRUCTURE & SAFETY 36 _____ (1) 1 ___ Isol. Fire Hazard 37 _____ (1) 2 ___ Fire Escapes 38 _____ (1) 3 ___ Fire Exits 39 _____ (1) 4 ___ Fire Exting. 40 _____ (1) 5 ___ Fire Alarm 41 _____ (1) 6 ___ Exit Lights 42 _____ (1) 7 ___ Ventilation 43 _____ (1) 9 ___ Dir. for Escape 44 _____ (2) (a) Space heaters 45 _____ (2) (b) Room Size 46 _____ (2) (c) Smoke Detection 47 _____ (2) (d) Door Locks 48 _____ (2) (e) Screens HFS 195.10 MAINTENANCE 49 _____ (1) General 50 _____ (2) 1 ___ Clean Rooms 51 _____ (2) 2 ___ Main 52 _____ (3) Insect & Rodent Control 53 _____ (4) Premise HFS 195.11 REGISTRATION 54 _____ Guest Registration

SIGNATURE - Licensee or Employee

SIGNATURE - Sanitarian

REGIONAL OFFICE - White copy

OPERATOR - Pink copy

CENTRAL OFFICE - Pink copy