8/1/2017 FSSAI Licensing & Registration System

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Form 'B'
[See Regula on 2.1.2, Regula on 2.1.3 and Regula on 2.1.7]
Applica on for License / Renewal of license under Food Safety and Standards Act, 2006
Applica on Reference No.: 20161124144216110 Applica on Type: New License
SAINATH BAR AND RESTAURENT, CHANDRA R
Name of Company/ Organiza on: Applica on Date: 24/11/2016
POOJARI
PREM NAGAR DARGA ROAD BHANDUP
W PREM NAGAR , Greater Mumbai
Address: Kind of Business: Restaurants
Ward-S, Greater Mumbai, Mahara
shtra-400078

Registered Office Detail(s)

Address PREM NAGAR DARGA ROAD BHANDUP W PREM NAGAR District Greater Mumbai
State Maharashtra Pin Code 400078

Address of Premises for which license is applied

Address PREM NAGAR DARGA ROAD BHANDUP W PREM NAGAR District Greater Mumbai
State Maharashtra Pin Code 400078

Correspondence Address
Address PREM NAGAR DARGA ROAD BHANDUP W PREM NAGAR District Greater Mumbai
Pin Code 400078
State Maharashtra
Contact Informa on
Telephone No. Fax
Mobile No. 9930217224 Email-ID [email protected]
Person in charge of opera ons
Name CHANDRA R POOJARI Pin Code 400078
Qualifica on CHAIRMAN Contact No.
Address PREM NAGAR DARGA ROAD BHANDUP W PREM NAGAR Mobile No. 9930217224
State Maharashtra Email-ID [email protected]
District Greater Mumbai Photo ID ACD,874546415578

Person responsible for complying with condi ons of License

Name CHANDRA R POOJARI Pin Code 400078

Qualifica on CHAIRMAN Contact No.
Address PREM NAGAR DARGA ROAD BHANDUP W PREM NAGAR Mobile No. 9930217224
State Maharashtra Email-ID [email protected]
District Greater Mumbai Photo ID ACD,874546415578

Kind of Business : Food Business Operator

Restaurant
Sl.No Food Product Category
1 99 - Substances added to food
Already Holding License No
Other License No
Is holding PA/NOC

Document(s) Details
SNo. Document(s) Submission Type Document Uploaded / FBO Remarks
Form-B Duty completed and signed (In Duplicate) by the Proprietor/Partner or the Authorized
1 Electronically View
Signatory
Blueprint/layout plan of the processing unit showing the dimensions in metres/square metres and
2 Not Applicable
opera on-wise area alloca on (mandatory for manufacturing and processing units only)
List of Directors/Partners/Proprietor/Execu ve Members of Society/Trust with full address and
3 Electronically View
contact details (mandatory for companies only)
Name and List of Equipments and Machinery along with the number, installed capacity and horse
4 Electronically View
power used (mandatory for manufacturing and processing units only)
Photo I.D and address proof issued by Government authority of
5 Electronically View
Proprietor/Partner/Director(s)/Authorised Signatory. (op onal)
https://foodlicensing.fssai.gov.in/SLS/FBO/SL_FBOAppDetails.aspx?ReqID=32323221 1/2
8/1/2017 FSSAI Licensing & Registration System
6 List of food category desired to be manufactured. (In case of manufacturers) Not Applicable
Authority le er with name and address of responsible person nominated by the manufacturer along
7 with alterna ve responsible person indica ng the powers vested with them viz assis ng the officers Electronically View
in inspec ons, collec on of samples, packing & dispatch. (for manufacturers / processors)
Analysis report (Chemical & Bacteriological) of water to be used as ingredient in food from a
8 recognized/ public health laboratory to confirm the potable (mandatory only for manufacturing and Not Applicable
processing units only)
9 Proof of possession of premises. (Sale deed/ Rent agreement/ Electricity bill, etc.) (op onal) Electronically View
Partnership Deed/Affidavit of Proprietorship/Memorandum & Ar cles of Associa on towards the
cons tu on of the firm. (op onal) – For MoA - Three pages need to be uploaded (First page -
10 Electronically View
Cer fica on of incorpora on, Second page - Authoriza on of food business ac vity and Third page -
list of directors with addresses)
Copy of cer ficate obtained under Coop Act - 1861/Mul State Coop Act - 2002 in case of
11 Electronically View
Coopera ves. (wherever applicable)
12 NOC & Copy of License from manufacturer (mandatory for relabellers and repackers only) Electronically View
13 Food Safety Management System plan or cer ficate (if any) Electronically View
Source of milk or procurement plan for milk including loca on of milk collec on centres etc. in case
14 Not Applicable
of Milk and Milk Products processing units.(wherever applicable)
15 Source of raw material for meat and meat processing plants. (wherever applicable) Not Applicable
Pes cide residues report of water in case of units manufacturing packaged drinking water, packaged
16 Not Applicable
Mineral water and/or carbonated water from a recognised/ public health laboratory
17 Recall plan wherever applicable, with details on whom the product is distributed. (op onal) Not Applicable
18 NOCs from Municipality or local body. (op onal) Not Applicable
19 Form IX: Nomina on of Persons by a Company alongwith the Board Resolu on Not Applicable
20 Cer ficate provided by Ministry of Tourism (HRACC) (Applicable for Hotels only) Not Applicable
For Transporters-Suppor ng documentary proof for Turnover or self declara on of number of
21 Not Applicable
vehicles
22 Upload Produc on unit photograph Not Applicable

Payment Details

Amount Rs. 10000 Payment Mode CHALLAN

Sl. No. Amount(INR) Treasury Challan No. Issue Date Major Head Sub Major Head Group Sub Head Sub Head Con gency Fund MH/Service Major Head DDO Code Bank Branch Code
1 10000 MH006214322201617 24/11/2016 0210 04 01 01 104 7107 SBIN0000562

Place :
______________________________________
Date : (Signature of the applicant/authorized signatory)
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