Food Establishment Verification of Correction

2. All orders from inspection must be addressed on this form. Detail corrective action taken for each order issued on the inspection report.

4. Establishment Name*

5. Inspection Date*
   Inspection Date

7. Name of Person in Charge*

9. Email Address*

10. Phone Number*

12. Establishment Address*

13. City*

14. Zip Code*

16. Minnesota Rule Number*

17. Date of Compliance*
    Date of Compliance

19. Corrective Action Taken*

    Example: We have developed new policy to eliminate bare hand contact with ready to eat foods. Staff will use tongs, glove, deli paper, or utensils to handle ready to eat foods.

21. Minnesota Rule Number

22. Date of Compliance
    Date of Compliance

24. Corrective Action Taken

26. Minnesota Rule Number

27. Date of Compliance
    Date of Compliance

29. Corrective Action Taken

31. Minnesota Rule Number

32. Date of Compliance
    Date of Compliance

34. Corrective Action Taken

36. THE MINNESOTA DATA PRACTICES ACT requires that we inform you of your rights about the private data we are requesting on this form. Private data is available to you, but not to the public. Your e-mail address is private information. We are requesting this data to register a bee apiary on your property. You are not legally required to provide the data; however, refusing to supply the data may cause your registration to not be processed. In addition, this data can be shared by Edina City Staff. Your signature on this application indicates you understand these rights. Your residence address and telephone number will be considered public data unless you request this information to be private and provide an alternative address and telephone number. Please choose accept below to indicate that you have read this notice.*

    1. I agree.

38. Alternate Address

39. Alternate Phone

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field