and/or

  

Missouri Department of Health Senor Services 
Bureau of Environmental Health Services Foggce 
. . 4, 3, a .v a? ?53. 1
Lodging Establishment Inspection Report USE ONLY . ., Establishment Name . I Name Owner General Manager
.7 x: MI 
PhySIcal Address ?a ,2 . . City i I, . Zip
,vn. . 131,412) ?f j: -7
Mailing Address City Zip
- 3 
County This inspection is a(n) Telephone; I No. of No. of Rooms is current lodging license displayed?
I El initial El Follow-up of g, '7 Stories I Yes No new
Rooms Inspected . - Water'SuppIy? iWastewater 
j. 4 . . El Private EfPubiic El Private B?Public
v? Water sample taken [1 Yes JReguiated by: El DHSS EFDNR
Swimming PooislSpa's (check all that apply)
indoor pool Outdoor pool El Spa El Pool larger than 2000 square feet Cl
Please check ifthe following New Lodging Establishments - . . . -, . ..
local ordinances apply . - - . A . -, . . . 
_IFire Safety i] Wiring Smoke detectors hardwired 3479s El No El Swimming Pool Certi?ed El Yes No EFNIA
El Plumbing Fire alarm system installed [?ies No Building Certi?ed to National Standards or Occupancy
Cl Swimming Pools/Spas . kl . I BY 34*: IA :ermrt IB ?Id? 0 Yes [1 kilo 
Fuel Burning Appliances SprIn er system Instal ed es 0 IstorIca ur Ing Ci es 
Basedonanin pectton this dammitems irradged?Out" beiswiden?fy nonoompiiansein . np?o or
inthisnotrcemayresuitin revoee?onofyogril? ,ngicei 

when may request a hearing before ?the Department Director-upon ?tirig ten days. 

    

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(RSMOprose 315. 005-065; 19 CSR 20-3. 050) T,
In?n Com ?ance Out=Not In Compliance, stpIaIn on add'w :NOsNet Observed Applicable .
A53: Waist Suppiyammwa?r In .00: NO NIA ?Sba?oit E: FimSafo?ty I -L {033$ . Elli-IA
1. Approved source construction and operation I 1. Textiles, hangings and mirrors m/
2. Complies with water qualigh standards 3" 2. Fire extinguisher type, inspected, and location 
3. Chlorinator maintained and operated properly 3. Vertical openings ?re-rated, self-closing 
4. Wastewater operation and maintenance 4. Doors, self-closing and ?re-rated 
Somatic: ,S?nita?opl?ousekeepinl 5. Smoke detectors hardwired, installed, good repair 
1. Walls, ?oors and ceilings in good repair v? 6. Evacuation route and plan. installed, available 
:I?Housekeeping practices and furnishings 7. Stairs and ramps, maintained, storage 
3.3 Towels and bed linens clean 8. Means of egress, number, maintained 
4/ Mattresses and box springs clean v" 9. Handrails and balconies maintained and appropriate 
Pest control procedures It" Sec?onFr S?'vlmming? . .. 
6. ice machines, scoops, liners clean protected 1 Fence, gate adequate, proper closure mechanism v?
7. Garbage storage and disposal 2. Boundary line, pool depth properly marked
8. Premises maintained, plant growth controlled if i 3. Deck is clean and in good repair
Food Insp?'c?fio'nbo?ndudtod A. 4. Lifesaving equipment adequate. mod repair
9. Food, equipment and single service/use I 5. Pool clarity, pH, disinfectant, temp. maintained
10. Food protected from contamination 6. Steps, ladders, and handrails installed, good repair
11. Facilities to wash, rinse and sanitize 7. Adequate ventilation
12 Handwashing facilities/hygienic practices 8. Electrical outlets, proper protection distance
Section 0: Life 9. Records maintained and signs posted
1. Combustible/toxic items usage and storage 10. First aid kit available 4,
2. Building maintained to assure safe conditions 11. Lighting adequate and In good repair 
3. CO detectors hardwired, installed, good repair y? G: leanW
4. GFCI, outlets switches installed, good repair v? ,1 quipment adequate, good repair 
5. Exit signs installed, good repair I 2. Ventilation adequate, plumbing, restrooms 
6. Emergency lighting installed, good repair 3. relief valves adequate, good repair V,
7. Electric panel protected, labeled, good repair i/ 4. Relief valve discharge pipes installed, adequate 
Required Annual Third Party Inspections 5. Back?ow, air gaps, no cross connections 
1. Fire Alarm System Section H. Heating 8- Cooiiqg 
2. Sprinkler System 1 Unvented fuel- -burning appliance/space heater v?
3. Local Fire and Building Codes/Ordinances 2. Fire resistant room or sprinkler head 
4. Current Boiler/Pressure Vessels MDPS ..
Certi?cation 3. Location of heating/cooling units V,
5. Back?ow Device(s) Test 4. Ventilation of appliances and utility rooms 
6. Liquid Propane Leak Test 5. Operation and condition adequate 3/
BY (PRINT NAME and SIGN) EPHS NUMBER AGENCY FTELEPHONE
1? I I I I. It?; 31'; {5?1 I -. 
LICENSING YEAR DATE FOLLOW UP DATE
APPROVED YES .. 
RECEIVED BY (PRINT NAME AND TITLE and SIGN) PAGE 1 OF 
Pa TEL own-I A/amalz 1% I
Canary/Central Of?ce Pink/Local Of?ce E9.02

 

MO 580-0883 (6- 16)

Distnbution: White/Owner

Missouri Department of Health anc or Services
Bureau of Environmental Health Serwces 
Lodging Establishment Inspection Report Page; 

 

Name Physical Address

I - . . 
-5 't/f ff. 

CTED BY
I ?f

5 I 

MO 580-2569 (6-16) Distribution: White/Owner

I
.s.

3?
a 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Missouri Department of Health Senior Services 
Bureau of Environmental Health Services :5 . . . 
Lodging Establishment Inspection Report - USE. ONLY. .. . g] 
. cw? ?tll .) .
Establishment Name Name 6 Owner "El General Manager
I . 1'
Physical Address tony? Zip 
Mailing Address City Zip
County This inspection is a(n) Telephone I No. of No. of Rooms Is the current lodging license displayed?
Initial El Annual B?Follow-up . Stories I 5/ it? Yes [1 No new
Rooms inspected Water Supply Wastewater 
.1 r? Private El Public El Private Public
Water sample taken Yes No Regulated by: DHSS El DNR
Swimming (check all that 229in . .
Indoor pool Cl Outdoor pool [3 Spa [1 Pool larger than 2000 square feet 
Please check if the following New Lodging Establishments 
local ordinances apply - . - .
DYes Cl No El Swimming Pool Certi?ed 3 Yes No 1: 

 

Fire Safety i] Electrical Wiring smoke detectors hardwired

Plumbing

Fire alarm system installed

:Yes No [3 

Permit

Building Certi?ed to National Standards or Occupancy

Yes No

 

Swimming Pools/Spas
Fuel Burning Appliances

Sprinkler system installed

[Yes No :1 

 

Historical Building Cl Yes i] No 

 

 

Based on an inspection this day, the lter Wed ?Out? below identity noncompliance
'rer'Iewal of your lodging license. Failure.- to comply with any time for corrections 

in rations ortaciittles which must be corrected prior to issuance er
in this notice may result In revocation ofyouriodging license

and/or prosecution. Owners may request a hearing before the Department Director upon tiling a written r?e?que'?t Within ten days after receipt of th? notice

(RSMO 315 005-065, i9 CSR 20-3. 050)

 

Nos-Hot Observed . Applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Itisir; Compliance Out-:Not In Compliance. explain on additional Ms)

Section A B: water Supply Wastewater In - Out MIA Section Fire SatayApproved source, construction and operation I 1. Textiles hangings and mirrors 
2. Complies with water quality standards I 2. Fire extinguisher type, inspected, and location
3. Chlorinator maintained and operated properly 3. Vertical openings ?re-rated, self-closing 
4. Wastewater operation and maintenance w/ 4. Doors, self-closing and ?re-rated 
Section c: wSerritaticmlt?loriseiteegiigg 5. Smoke detectors hardwired, installed, good repair i
1. Walls, ?oors and ceilings in good repair 6. Evacuation route and plan, installed, available
2. Housekeeping practices and furnishings 7. Stairs and ramps, maintained, storage
3. Towels and bed linens clean 8. Means of egress, number, maintained 
4. Mattresses and box springs clean 9. Handrails and balconies maintained and appropriate 
5. Pest control procedures Section F: Swimnting?PooislSpae .. .
6. ice machines, scoops, liners clean 8. protected 1. Fence, gate adequate proper closure mechanism 
7. Garbage storage and disposal 2. Boundary line, pool depth properly marked I
8. Premises maintained, plant growth controlled 3. Deck is clean and in good repair 1
Food aceot?lngt?o' 4. Lifesaving equipment adequate, good repair 
9. Food, equipment and single service/use 5. Pool clarity, pH, disinfectant, temp. maintained 
10. Food protected from contamination I 6. Steps, ladders, and handrails installed, good repair I
11. Facilities to wash, rinse and sanitize 7. Adequate ventilation i
12. Handwashing facilities/hygienic practices 8. Electrical outlets, proper protection distance
Section D. Life Safety 9. Records maintained and signs posted
1. Combustible/toxic items usage and storage w" 10. First aid kit available 
2. Building maintained to assure safe conditions i 11. Lighting adequate and in good repair 3'
3. CO detectors hardwired, installed, @od repair 1 Section G: Plumbing?lechanicai 
4. GFCI, outlets switches installed, good repair I 1. Equipment adequate, good repair 
5. Exit signs installed, good repair I 2. Ventilation adequate, plumbing, restrooms 
6. Emergeng lighting installed, good repair 3. relief valves adequate, good regair 
7. Electric panel protected, labeled, good repair 4. Relief valve discharge pipes installed, adequate ,3 
Required Annual Third Party inspections 5. Back?ow, air gaps, no cross connections it?
1. Fire Alarm System Section H: Heating 8; cooling 
2. Sprinkler System 1. Unvented fuel- b-urning appliance/space heater
3. Local Fire and Building Codes/Ordinances - 2. Fire resistant room or sprinkler head i
4. Current Boiler/Pressure Vessels MDPS i 5

Certi?cation i 3. Location of heating/cooling units ,3
5. Back?ow Devicegs) Test 4. Ventilation of appliances and utility rooms 4

 

 

 

 

 

 

 

 

 

6. Liquid Propane Leak Test

 

5. Operation and condition adequate

 

INSPECTED BY (PRINT NAME and SIGN)

?a

.4

 

EPHS NUMBER AGENCY



vii-?2 

I
TELEPHONE

Ir- ,ilJET. . 
.. . .
LICENSING YEAR DATE INSPECTED FOLLOW UP DATE

 

APPROVED RECEIVED BY (PRINT NAME AND TITLE and SIGN)
(ti Pal cl 0 Wm?



qu?lig

PAGE 1 

 

 

MO 580-0883 (6-16) Distribution: White/Owner

Canary/Central orn?e'

Pink/Local Of?ce

 

Missouri Department of Health an; Jr Services
Bureau of Environmental Health Services

Lodging Establishment inspection Report Page .of .

 

Establishment Name Physical Address

CTED BY RECEIVED BY

-- 

MO 580-2569 (6-16) Distribution: White/Owner Of?ce