In House in Lake Butler

Reason: FS 500.04; FS 500.10 Adulterated.* Prevention of Food Contamination: Insects. rodents, and animals not present. : , Comments: All affected areas must be adequately cleaned and sanitized. In addition, the food establishment must develop and implement a pest management control program. Contact the Business Center at (850) 245-5520 or FoodSafety@FDACS. gov to request a Food Safety Inspector visit for written release. FDACS-14325 Rev. 05/22 Print Date: 9/19/2022 Page 4 of 5 Scanned by CamScanner When the department or its duly authorized agent finds, or has probable cause to believe, that any food or food-processing equipment is in violation of this chapter or any rule adopted under this chapter so as to be dangerous, unwholesome, fraudulent, or insanitary within the meaning of this chapter, an agent of the department may issue and enforce a stop-sale, stop-use, removal, or hold order, which order gives notice that such article or processing equipment is, or is suspected of being, in violation and has been detained or embargoed and which order warns all persons not to remove, use, oF dispose of such article or processing equipment by sale or otherwise until permission for removal, use, or disposal is given by the department or the court. It is unlawful for any person to remove, use, or dispose of such detained or embargoed article or processing equipment by sale or otherwise without such permission in accordance with 500.172 (1) Florida Statutes AN ADMINISTRATIVE HEARING IS AVAILABLE FOR ALL ORDERS, NOTICES, AND REPORTS IN THIS SUPPLEMENTAL REPORT If you wish to contest the Department's action, you have the right to request an administrative hearing to be conducted in accordance with Sections 120.569 and 120.57, Florida Statutes and to be represented by counsel or other qualified representative. Your request for hearing must contain. 1. Your name, address, and telephone number, and facsimile number (if any). 2. The name, address, and telephone number, and facsimile number of your attorney or qualified representative (if any) upon whom service of pleadings and other papers shall be made. 3. A statement that you are requesting an administrative hearing and dispute the material facts alleged by the department, in which case you must identify the material facts that are in dispute (formal hearing), or that you request an administrative hearing and that you do not dispute the facts alleged by the department (informal hearing). 4. A statement of when (date) you received the Notice and the file number of this Notice. Your request for a hearing must be received at the address shown on this Notice within twenty-one (21) days of receipt of this Notice. If you fail to obtain a Release from this Notice or fail to request an administrative hearing within the twenty-one (21) day deadline you waive your right to a hearing and the Department may enter a Final Order imposing up to the maximum penalties as authorized by Florida Law. HEARING WAIVER AND WAIVER OF RIGHTS ON DESTROYED PRODUCTS 1 NIA the person in charge of DOLLAR GENERAL # 12840 hereby waive a notice and a hearing as provided in Chapter 120, Florida Statutes and waive all rights as provided on the last page of this report. N/A (Signature) ACKNOWLEDGEMENT A copy of this report has ole to the person in charge of the food establishment. Af | acknowledge receipt of Ld Z, lisf Signature of FDACS Representative KENNETH DAVIDSON, ENVIRONMENTAL SPECIALIST | CHERYL NICELY, STORE MANAGER Print Name and Title Signature gf Representative FOACS-14325 Rev. 05/22 Print Date: 9/19/2022 Page 5 of S Scanned by CamScanner