Appendix C - BEN Site Review Form~1.pdf
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- Attached to
- BEN Case Management System
- Solicitation number
- 90DETR-S3794
- Issued by
- Churchill County, Nevada
About this file
This document is an On-Site Business Practice Review Report Form used by Nevada's Bureau of Services to the Blind and Visually Impaired (BSB/VI) Business Enterprise of Nevada (BEN) Program to conduct comprehensive operational and financial assessments of BEN vending facility operators. The form, revised in May 2010 per Procedure #02-04, serves as the standardized evaluation instrument for monitoring operator compliance with program requirements and Nevada Administrative Code (NAC) regulations.
The review process encompasses multiple assessment categories including site history, previous findings and corrective actions, financial practices compliance, and operational standards across fourteen distinct focus areas. Operational evaluation criteria span hygiene and sanitation standards for operators and facilities, vending machine maintenance and cleanliness, marketing and merchandising practices, inventory management, equipment maintenance logs, customer service delivery, and posting requirements for partner agreements, health department permits and ratings, tax documentation (IRS Form 941 and Nevada Form TXR-01), insurance coverage verification (worker's compensation and liability), business licenses (state and local), BEN licenses, equipment inventory, federal and state labor law posters, and cash register operations per Nevada Revised Statutes 372.770. The financial review component includes examination of Profit and Loss statements and compliance with NAC 426 requirements. A risk assessment matrix evaluates twelve performance indicators to determine review frequency, with rating scales ranging from one (unacceptable) to five (excellent) for most operational categories. The form requires general ledger verification documentation including invoices, cancelled checks, and bank statements, and concludes with a corrective action plan section documenting findings, recommendations, responsible parties, and completion dates. Both Bureau Examiner Officer (BEO) and operator signatures are required to finalize the report, with provisions for operators to indicate agreement or disagreement with findings.
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Bureau of Services to the Blind and Visually Impaired (BSB/VI) Business Enterprise of Nevada Program (BEN)
Print Date 3/13/2025 Page 1 of 17 Print Time 1:16 PM
Bureau of Services to the Blind & Visually Impaired Business Enterprises of Nevada
Procedure #02-04 (Revised 05-11-2010 per KLY)
ON SITE BUSINESS PRACTICE REVIEW REPORT
OPERATOR NUMBER OPERATOR NAME
SITE NUMBER SITE LOCATION
SITE REVIEW DATE SITE REVIEW BY
SITE REVIEW NUMBER 01 02 03 04 05 06 07 08 09 10 11 12 13 14
Site History Summary
XXXX XXXXXXX took over this site on 10-29-2006.
XXXXX XXXXXXX has been in the program since XXX 20XX.
The last site review was done by XXXXX XXXXXXXXXX.
The last site review was done on XX-XX-20XX.
A ”Location Survey” was completed and it is attached to this site review.
Previous Findings and Status of Corrective Action
Comments made on the last site review relative to any “Previous Findings and Status of Corrective Action” are as follows on Page 2-
General Comments
Print Date 3/13/2025 Page 2 of 17 Print Time 1:16 PM
PREVIOUS FINDINGS AND STATUS OF CORRECTIVE ACTION
BEO
FINDINGS
BEO
RECOMMENDATIONS
PERSON
RESPONSIBLE
REVIEW
DATES
DATE
COMPLETED
00-00-2010
Print Date 3/13/2025 Page 3 of 17 Print Time 1:16 PM
FINANCIAL REVIEW CHECKLIST
FINANCIAL PRACTICES
CATEGORIES
SELECTED
BEO
FINDINGS
NAC 426
COMPLIANT
XXX 2010 P&L
SEC LINE
YES NO
XXX 2011 P&L
Print Date 3/13/2025 Page 4 of 17 Print Time 1:16 PM
OPERATIONAL REVIEW CHECKLIST
OPERATIONAL PRACTICES
RATING SCALE
Rating of 1 is Unacceptable
Rating of 2 is Below Standard
Rating of 3 is Standard
Rating of 4 is Above Standard
Rating of 5 is Excellent
ITEM I
HYGIENE OF OPERATOR AND FACILITY PERSONNEL
• Personal Cleanliness. 1 2 3 4 5
• Jewelry. 1 2 3 4 5
• Hand washing and fingernails. 1 2 3 4 5
• Clothing and Hair. 1 2 3 4 5
• Consumption of food and/or drink on site. 1 2 3 4 5
• Use of illegal drugs.
• Use of excessive legal drugs.
• Use of alcohol.
• Use of tobacco.
YES NO
YES NO
Comments (Required)
ITEM II
SANITATION AND GENERAL CONDITION OF THE FACILITY
1 2 3 4 5
Print Date 3/13/2025 Page 5 of 17 Print Time 1:16 PM
Unacceptable
Rating of 2 is Below Standard
Rating of 3 is Standard
Rating of 4 is Above Standard
ITEM III
VENDING MACHINES CLEAN AND TAGGED AND THE
CONTACT NAME AND PHONE NUMBER ARE DISPLAYED
ITEM IV
MARKETING AND MERCHANDISING
ITEM V
CONSUMABLE AND OTHER INVENTORY
Print Date 3/13/2025 Page 6 of 17 Print Time 1:16 PM
Unacceptable
Rating of 2 is Below Standard
Rating of 3 is Standard
Rating of 4 is Above Standard
ITEM VI
SLA PROVIDED EQUIPMENT MAINTENANCE LOG
MAINTAINED AND UP TO DATE
ITEM VII
SANITATION AND GENERAL CONDITION OF EQUIPMENT
ITEM VIII
CUSTOMER SERVICE DELIVERY
Print Date 3/13/2025 Page 7 of 17 Print Time 1:16 PM
Unacceptable
Rating of 2 is Below Standard
Rating of 3 is Standard
Rating of 4 is Above Standard
ITEM IX
FOR FUTURE USE
ITEM X CURRENT YES NO N/A
PARTNER AGREEMENT POSTED YES NO N/A
Document Number From 00-00-2010 To 00-00-2010 Photocopy of Partner Agreement Attached (Required) YES NO N/A
ITEM XI CURRENT YES NO N/A
HEALTH DEPARTMENT PERMIT POSTED YES NO N/A
Permit Number From 00-00-2010 To 00-00-2010 Photocopy of Health Department Permit Attached (Required) YES NO N/A
Print Date 3/13/2025 Page 8 of 17 Print Time 1:16 PM
ITEM XII CURRENT YES NO N/A
HEALTH DEPARTMENT RATING POSTED YES NO N/A
Rating From 00-00-2010 To 00-00-2010 Photocopy of Health Department Rating Attached (Required) YES NO N/A
ITEM XIII CURRENT YES NO N/A
HEALTH DEPARTMENT INSPECTION REPORT POSTED YES NO N/A
Inspection Rating From 00-00-2010 To 00-00-2010 Photocopy of Health Inspection Report Attached (Required) YES NO N/A
ITEM XIV CURRENT YES NO N/A
IRS FORM 941-PAYROLL TAX QUARTERLY REPORT POSTED YES NO N/A
EIN Number From 00-00-2010 To 00-00-2010 Photocopy of IRS FORM 941 Attached (Required) YES NO N/A
Print Date 3/13/2025 Page 9 of 17 Print Time 1:16 PM
ITEM XV CURRENT YES NO N/A
NV FORM TXR 01-STATE SALES TAX REPORT POSTED YES NO N/A
TID Number From 00-00-2010 To 00-00-2010 Photocopy of NV FORM TXR-01 Attached (Required) YES NO N/A
ITEM XVI CURRENT YES NO N/A
WORKER COMPENSATION INSURANCE COVERAGE POSTED YES NO N/A
Policy Number From 00-00-2010 To 00-00-2010 Photocopy of Declarations Page Attached (Required) YES NO N/A
ITEM XVII CURRENT YES NO N/A
LIABILITY INSURANCE COVERAGE [NAC 426.196] POSTED YES NO N/A
Policy Number From 00-00-2010 To 00-00-2010 Photocopy of Declarations Page Attached (Required) YES NO N/A
NAC 426.196 Requirements of insurance. (NRS 426.560, 426.670) The Bureau will:
1. Provide fire insurance and storekeeper’s liability insurance as may be necessary for all vending facilities;
2. Prescribe in each operating agreement the insurance that is required for the vending facility covered by the agreement, including the insurance that the operator is required to obtain;
3. Respond within 30 days to all written inquiries from an operator concerning the requirements of insurance for the vending facility; and
4. Ensure that each policy of insurance names the Bureau as an additional insured.
(Added to NAC by Bur. of Services to the Blind & Vis. Impaired, eff. 8-28-97; A by R091-00, 9-25-2000) http://leg.state.nv.us/NRS/NRS-426.html#NRS426Sec560 http://leg.state.nv.us/NRS/NRS-426.html#NRS426Sec670
Print Date 3/13/2025 Page 10 of 17 Print Time 1:16 PM
ITEM XVIII CURRENT YES NO N/A
BUSINESS LICENSE-STATE-REQUIRED IN NV POSTED YES NO N/A
License Number From 00-00-2010 To 00-00-2010 Photocopy of State Business License Attached (Required) YES NO N/A
ITEM XIX CURRENT YES NO N/A
BUSINESS LICENSE-LOCAL-MAY BE OPTIONAL POSTED YES NO N/A
License Number From 00-00-2010 To 00-00-2010 Photocopy of Local Business License Attached (Required) YES NO N/A
ITEM XX CURRENT YES NO N/A
BEN LICENSE POSTED YES NO N/A
License Number From 00-00-2010 To 00-00-2010 Photocopy of BEN License Attached (Required) YES NO N/A
Print Date 3/13/2025 Page 11 of 17 Print Time 1:16 PM
ITEM XXI CURRENT YES NO N/A
BEN EQUIPMENT INVENTORY POSTED YES NO N/A
BEN Site Number From 00-00-2010 To 00-00-2010 Photocopy of Signed Inventory Attached (Required) YES NO N/A
ITEM XXII CURRENT YES NO N/A
FEDERAL LABOR LAW POSTERS POSTED YES NO N/A
http://www.laborlawcc.com/Nevada-Federal-Combo-Poster-p107.html
MANDATORY FEDERAL LABOR LAW POSTERS
#1-USERRA
#2-OCCUPATIONAL SAFETY AND HEALTH ACT – OSHA
#3-FEDERAL MINIMUM WAGE - $7.25
#4-EMPLOYEE POLYGRAPH PROTECTION
#5-EQUAL EMPLOYMENT OPPORTUNITY - EEO
#6-FAMILY & MEDICAL LEAVE ACT - FMLA
#7-NATIONAL LABOR RELATIONS ACT-NLRA
FEDERAL LABOR LAW POSTERS MUST BE POSTED IN A CONSPICUOUS LOCATION
ITEM XXIII CURRENT YES NO N/A
STATE LABOR LAW POSTERS POSTED YES NO N/A
MANDATORY NEVADA LABOR LAW POSTERS
#1-WAGE & HOUR LAWS
#2-UNEMPLOYMENT INSURANCE
#3-LIE DETECTOR TESTS
#4-SAFETY & HEALTH PROTECTION
#5-DISCRIMINATION
#6-INJURIES ON THE JOB
#7-EMERGENCY PHONE NUMBERS
#8-TIP REPORTING
NV LABOR LAW POSTERS MUST BE POSTED IN A CONSPICUOUS LOCATION.
Print Date 3/13/2025 Page 12 of 17 Print Time 1:16 PM
ITEM XXIV
CASH REGISTER OPERATION
[1] Are cash register receipts being given out automatically at all cash registers and to all customers and for all purchases, as per NRS 372.770 and as per NAC 372.770?
YES NO N/A
[2] Do all cash register customer receipt tapes list the sites name and address and phone number?
[3] A copy of every cash register’s customer receipt tape is attached.
ITEM XXV
IS THE OPERATORS IRS FEDERAL INCOME TAXES CURRENT? YES NO N/A
ITEM XXVI
OPERATIONAL CONCERNS AND REQUESTS OF THE OPERATOR
BEO Comments and Concurrence (Required)
Print Date 3/13/2025 Page 13 of 17 Print Time 1:16 PM
ITEM XXVII
GENERAL LEDGER VERIFICATION
LEDGER ITEMS REFERNCED
LINE LEDGER COMPANY INVOICE INVOICE INVOICE
NUMBER PAGE NAME DATE NUMBER AMOUNT
1 00-00-2012 $ 5555.00 2 00-00-2012 $ 3 00-00-2012 $ 4 00-00-2012 $ 5 00-00-2012 $
Were the above listed LINE 1 Ledger items provided?
If not, Please explain below-
INVOICE YES NO N/A
CANCELLED CHECK YES NO N/A
BANK STATEMENT YES NO N/A
Were the above listed LINE 2 Ledger
If not, Please explain below-
INVOICE YES NO N/A
Print Date 3/13/2025 Page 14 of 17 Print Time 1:16 PM
ITEM XXVII
GENERAL LEDGER VERIFICATION-CONTINUED
Were the above listed LINE 3 Ledger
If not, Please explain below-
INVOICE YES NO N/A
Were the above listed LINE 4 Ledger
If not, Please explain below-
INVOICE YES NO N/A
Were the above listed LINE 5 Ledger
If not, Please explain below-
INVOICE YES NO N/A
Print Date 3/13/2025 Page 15 of 17 Print Time 1:16 PM
RISK ASSESSMENT
ASSESSMENT POSITIVE NEGATIVE
1. Profit and Loss Statements thoroughly completed: YES NO NO
2. Profit and Loss Statements are submitted on time: YES NO NO
3. Loan payments, if any, are on time: YES NO NO
4. No subsidy requests have been received this quarter: NO YES NO
5. Cost of goods is appropriate: YES NO NO
6. Net profit remains stable: YES NO NO
7. Payroll costs are reasonable: YES NO NO
8. Equipment repair/replacement requests reasonable: YES NO NO
9. No complaints received from the property manager: NO YES NO
10. No complaints have been received from customers: NO YES NO
11. The last on Site Review noted NO corrective action: NO YES NO
12. There have been NO requests for assistance: NO YES NO
Other Conditions impacting risk rating:
RISK RATING
Number of negative risks above> 0 1 2 3 4 5 6 7 8 9 10 11 12
0 negative risks require annual review.
1 negative risk requires monthly review until resolved.
2 negative risks require bi-weekly review until resolved.
3 negative risks require weekly review until resolved.
Print Date 3/13/2025 Page 16 of 17 Print Time 1:16 PM
CORRECTIVE ACTION PLAN
BEO
FINDINGS
BEO
RECOMMENDATIONS
PERSON
RESPONSIBLE
REVIEW
DATES
DATE
COMPLETED
00-00-2010
Print Date 3/13/2025 Page 17 of 17 Print Time 1:16 PM
ON SITE BUSINESS PRACTICE REVIEW REPORT
OPERATOR NUMBER OPERATOR NAME
SITE NUMBER SITE LOCATION
SITE REVIEW DATE SITE REVIEW BY
SITE REVIEW NUMBER 01 02 03 04 05 06 07 08 09 10 11 12 13 14
Report completed by
BEO Signature
Date
Agree with findings
Operator Signature
Disagree with findings
Operator Signature
| ON SITE BUSINESS PRACTICE REVIEW REPORT |
| Previous Findings and Status of Corrective Action |
| FINANCIAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| OPERATIONAL REVIEW CHECKLIST |
| RISK ASSESSMENT |
| CORRECTIVE ACTION PLAN |
| PERSON RESPONSIBLE |
| FINANCIAL PRACTICES |
| OPERATIONAL PRACTICES |
| RATING SCALE |
| ITEM I |
| HYGIENE OF OPERATOR AND FACILITY PERSONNEL |
| OPERATIONAL PRACTICES |
| RATING SCALE |
| OPERATIONAL PRACTICES |
| RATING SCALE |
| OPERATIONAL PRACTICES |
| RATING SCALE |
| PERSON RESPONSIBLE |
| BEO Signature |
| Operator Signature |
| Operator Signature |
ON SITE BUSINESS PRACTICE REVIEW REPORT
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