SAFETY IS A PRIORITY Safety Committee Step 1 of 14 7% Date* MM slash DD slash YYYY Who is Completing the Report?* First Last Restaurant*Pick OnePacific Ave #802Wilson Way #969Lower Sacramento Road #3017Lodi Avenue #3580Charter Way #4111Tracy Blvd #4147Ben Holt #4643Elk Grove Blvd #4804Center Street #6216Waterloo Road #7058Louise #8195Floyd #10338Kettleman Lane/99 #10555Galt #10852March Ln. & West Ln. #1179711th Street #12264Martell #13329Westley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681Reynolds Ranch #40627Weston Ranch #40735GSRG #1000Reason For Report* Monthly Accident or Requested by Benefits Department Safety Committee Member 1* First Last Signature*Safety Committee Member 2* First Last Signature*Safety Committee Member 3* First Last Signature*Safety Committee Member 4* First Last Signature*Safety Committee Member 5* First Last Signature* Parking Lot & Trash Disposal AreasAre parking lots well maintained & free from pot holes & tripping hazards?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre parking lots well marked to indicate traffic patterns?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre parking lots well lit at night?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre speed bumps & guard posts painted for easy visibility?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre gas meters & electrical transformers protected by guard posts?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all entry & exits markings present at intersection with drive-thru lanes?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all walkways & curbs in good repair & well lit?* Yes No Please describe the damage*Go to goldenstatemcd.com/request and submit a construction work orderAre all pull forward/mobile order signs filled & stabilized?* Yes No Is the corral area locked & secured to prevent access?* Yes No If you do not have a lock, contact your supervisor to purchase oneWhat needs to be added?*Go to goldenstatemcd.com/request and submit a construction work orderIs combustible trash stored away from the building?* Yes No Please describe any issues in Parking Lot & Trash disposal areas. If none, state none.* Dining Room & Restroom AreasAre floors in good repair & properly cleaned?* Yes No If floors are not in good repair, go to goldenstatemcd.com/request and submit a construction work orderAre wet floor cones used to indicate wet floors?* Yes No Remember - NO A frame wet floor signs should be in the restaurant!How many wet floor cones are in the restaurant?*Please enter a number from 0 to 10.If your answer is 0, requests for more are at the end of this formAre wet floor cones clean & in good repair?* Yes No When mopping, is the Dry Mop used after every section mop?* Yes No The new scrubbing machine should be your main source of cleaning the floorsIs furniture in good condition?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderDoes the restaurant have high chairs?* Yes No Are high chairs in good condition, clean & stored out of traffic areas?* Yes No No high chairs Are there any gaps under or on the sides of the front doors? (Gaps where pests can come into the building)* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderAre restrooms in good repair? (No leaking faucets, toilets running, etc.)* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre restroom hand dryers in good repair & working?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre restroom hand sinks @ 100 - 108*F?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderAre restrooms clean & free of water accumulation?* Yes No Is there a "Caution: Slippery When Wet" sign posted in both restrooms?* Yes No Is there an "Employees Must Wash Hands" sign posted in both restrooms?* Yes No Please describe any issues in Dining & Restroom areas. If none, state none.* PlayPlaceDoes the PlayPlace have hand sanitizing wipes available?* Yes No Is the PlayPlace clean & free from accumulated grime, food residue or other visible accumulated soils?* Yes No Is all PlayPlace equipment approved & is safety maintained?* Yes No No cracks, holes, tears or other hazardsIs the Safe play & zone designated age appropriateness message displayed?* Yes No Are tables & benches in the PlayPlace in good condition & free from sharp edges or cracks?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all exit signs illuminated in the PlayPlace?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre emergency exit door alarms working in the PlayPlace?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre floors in the PlayPlace in good repair & properly cleaned* Yes No If floors are not in good repair, go to goldenstatemcd.com/request and submit a construction work orderAre there any holes in the walls or ceilings in the PlayPlace?* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderPlease explain where holes are located:* Do all electrical outlets in the PlayPlace have child resistant covers?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderPlease provide the date of your last PlayPlace Inspection* MM slash DD slash YYYY Please describe any issues in the PlayPlace. If none, state none.* Kitchen & Service AreasDo Drive Thru windows have locks that are in good operating condition that are secured when unattended?* Yes No Are aisle ways & traffic paths free of obstructions & tripping hazards?* Yes No Does the restaurant have a cart to carry heavy items throughout the restaurant?* Yes No Heavy items like food boxes, ice, tea urns, etc. If no, please request on at the end of this formIs the cart free of cracks or other damage?* Yes No If no, please request one at the end of this formIs the cart USED to carry heavy items throughout the restaurant?* Yes No Heavy items like food boxes, ice, tea urns, etcAre floors dry, clean & free from grease build up?* Yes No Are grease filters clean, in place with no gaps or leaks?* Yes No If there are gaps or leaks, go to goldenstatemcd.com/request and submit a work orderAre scrap cans correctly put in place & do they fit tight?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderIs there any sitting water on the floor?* Yes No Please explain what is leaking & describe where it is leaking from:*Please describe any issues in the Kitchen & Service areas. If none, state none.* Electrical EquipmentIs the restaurant free from extension cords?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all electrical connections in good condition & equipment grounded?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all electrical panels free from obstruction & readily accessible?* Yes No All circuit breaker panels labeled correctly?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderDo any electrical cords need to be repaired or replaced? (Ex: cuts or abrasions on the cord)* Yes No If yes, go to goldenstatemcd.com/request and submit a work orderAre all Exit signs illuminated?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderIs emergency lighting tested & working properly?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all light fixtures over food preparation areas shielded against breakage?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderAre there any cracks in light fixture covers?* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderIs clean power (orange outlets) plugs only used for POS equipment?* Yes No If no, what is the piece of equipment plugged into the orange plugs? What piece of equipment is plugged into the orange plugs?*Are there any open electrical junction boxes, outlets or loose wiring that can be seen?* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderPlease describe any issues with electrical equipment. If none, state none.* Storage & Refrigeration AreaAre only approved cleaning products/chemicals being used, properly stored & in their original container/packaging or an appropriately labeled secondary container away from food?* Yes No Does this restaurant have a compactor?* Yes No Does the compactor have a "NO MINORS" sticker visible? (NOTE: The small 18 with a cross through sticker does not count)* Yes No Remember - NO Minors!Are all employees trained on proper compactor use?* Yes No Are storage aisle floors free of boxes, cartons or anything else?* Yes No Are heavier items stored on lower shelves to prevent injury?* Yes No Only light items stored on top shelves in both stock room & walk insIs the emergency interior latch for coolers & freezers in good condition?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderIs there a sign posted on cooler & freezer doors stating, "Warning: Verify that no one is inside prior to locking door!"* Yes No Is the freezer free of ice build up?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderAre back up CO2 tanks chained together?* Yes No Is the back door alarm working on all back doors?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderIs the back door alarm in use?* Yes No Do not prop the back door open with a cone!Are there any gaps under or on the sides of the back doors? (Gaps where pests can come into the building)* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderPlease describe any issues with the Storage & Refrigeration areas. If none, state none.* Dish Washing AreaIs an approved Safety Mat kept in front of the dish washing area at all times?* Yes No Is the dish washing area kept clean?* Yes No Please describe any issues with the Dish washing areas. If none, state none.* LaddersHow many portable ladders does the restaurant have?*Please enter a number from 0 to 10.Are all portable ladders Safety Ladders (Non-slip, wide steps)?* Yes No Are fixed & portable ladders clean, free from excessive grease?* Yes No Do fixed & portable ladders have any damage or missing parts?* Yes No If yes, please place ladder in the trashAre ladders inspected before each use?* Yes No Are portable ladders secured during storage?* Yes No Please use a bungee cordPlease describe any issues with the ladders. If none, state none.* Fire ProtectionAre nozzle caps in place & aimed at cooking surfaces?* Yes No Has the Ansul system been inspected & serviced in the last 6 months?* Yes No If no, go to goldenstatemcd.com/request and submit a work orderWhen was the Ansul system inspected & serviced?* MM slash DD slash YYYY Are portable fire extinguishers properly mounted, easily accessible & clearly labeled with a fire extinguisher sign?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderAre all portable fire extinguishers inspected monthly with a manager's sign off?* Yes No Please describe any issues regarding Fire Protection. If none, state none.* MiscAre there any openings in the ceiling?* Yes No If yes, go to goldenstatemcd.com/request and submit a construction work orderAre the proper face shields, aprons & filtering gloves used during the filtering process?* Yes No Does the restaurant have 2 sealed eyewash bottles at the emergency eyewash station?* Yes No If you do not have 2 sealed, unexpired eyewash bottles, please request a replacementPlease list expiration date for eyewash bottle #1* MM slash DD slash YYYY If bottles are expired, please request a replacementPlease list expiration date for eyewash bottle #2 MM slash DD slash YYYY If bottles are expired, please request a replacementAre ALL employees wearing an approved type of non slip shoes?* Yes No AdministrativeIs there a First Aid kit available?* Yes No Is the First Aid kit stocked & located in a spot that is easily accessible to all employees?* Yes No Is safety top of mind during all shifts?* Yes No Is the evacuation plan posted?* Yes No Are all employees trained & understand the posted evacuation procedure plan?* Yes No Located in Jolt > Information > Critical Action Plan > Safety HandbookIs the wrench to shut off gas supply located in an easily accessible place?* Yes No Do all employees know where the gas shut off to the restaurant is located?* Yes No Is there a Caution sign present to notify gas shut-off before disconnecting?* Yes No If no, go to goldenstatemcd.com/request and submit a construction work orderIs there any tile that is in need of repair?* Yes No If yes, have your Supervisor reach out to FrankDoes the restaurant have a proper procedure in place to outage equipment when service/repair is required?* Yes No Are all employees trained on FRED's: Crew - Food Safety?* Yes No Are all employees trained on Biohazard Non Food Clean Up?* Yes No Have managers & crew received security training?* Yes No Can all managers describe the proper security procedures that need to be followed?* Yes No Are all new employees given a safety tour on their first shift?* Yes No Are all employees trained on use of fire extinguisher?* Yes No Is the fire extinguisher training documented?* Yes No Are all employees trained on how to find emergency phone numbers in the Safety Handbook in Jolt?* Yes No Located on the Digital Food Safety iPad > Jolt App > Information > Critical Action Plan > Safety HandbookAre CO2 Detectors, warnings & equipment installed correctly & operational?* Yes No Is the CO2 Detector display free of any error messages?* Yes No Are any unsafe work practices observed that could result in an injury or property damage?* Yes No Call Pardini's Central Station (510-584-0501) and test panic buttons* I contacted Central Station, All panic buttons work I contacted Central Station, Most panic buttons work I contacted Central Station, No panic buttons work I did not contact Central Station If any panic buttons are non responsive to the test, please have your RM contact Pardini's (1-209 931 5382) and let them know which ones are faulty. Please describe the unsafe work practices:*Are reflective vests with pockets used for Hand Held Order Taking, travel paths & to take out parked or curbside orders? Are reflective vests without pockets worn by the maintenance person?* Yes No Is the Hotline phone number & suggestion email posted?* Yes No Who was your Safety Star for the month? Please share the event below*Please recognize a team member for a safety act that was unprompted from this past month. Items needed from GSRG office* Blue Bandaids Bungee Cords Burn Gel "Caution: Slippery When Wet" Sign Dishwashing Sink Mat "Employees Must Wash Hands" Sign Eyewash Bottle Face Shield Filtering Apron Filtering Gloves Reflective vests (with pockets) Reflective vests (without pockets) Thermolabels Transfer cart "WARNING: Verify that no one is inside prior to locking door" Sign Wet Floor Cones None Check all that apply.Number of Eyewash Bottles Needed*Please enter a number from 1 to 2.Number of "Caution: Slippery When Wet" Signs Needed*Please enter a number from 1 to 2.Number of "Employees Must Wash Hands" Signs Needed*Please enter a number from 1 to 2.Number of "WARNING: Verify that no one is inside prior to locking door" signs Needed*Please enter a number from 1 to 2.Number of Reflective Vests Needed*Please enter a number from 1 to 2.Number of Bungee Cords Needed*Please enter a number from 1 to 2.Number of Wet Floor Cones Needed*Please enter a number from 1 to 5. Safety Committee Report CompletionDate* MM slash DD slash YYYY Signed By* First Last Written Signature*
