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Application

The document is an application for renewal of food business registration under the Food Safety and Standards Act, 2006 in India. It provides details of the applicant such as name, address, contact information, food items to be sold, payment receipt and declaration agreeing to comply with regulations.

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10 views

Application

The document is an application for renewal of food business registration under the Food Safety and Standards Act, 2006 in India. It provides details of the applicant such as name, address, contact information, food items to be sold, payment receipt and declaration agreeing to comply with regulations.

Uploaded by

lambda-7607ff
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Food Safety Compliance System (FoSCoS)

https://foscos.fssai.gov.in
Form A
[See Regulation 2.1.1, Regulation 2.1.7]

Application for Registration under food safety and Standards Act,2006

Application No: 30240301115916582 Application Type: Renewal


Name of Applicant / SamSim Kichen Application Date: 01-03-2024
Company: Kind of Business: Food Services -
Designation: Individual Restaurants, Food
Expiry Date: 07-03-2026 Services - Food
Vending
Establishment, Food
Services - Petty
Retailer of snacks/tea
shops
Certificate No: 22123682000105

Address of Premises Where Food Business Is Located

Address: House no 98 State: Punjab


Rattan Nagar
Sub-Division/Station/ Patiala-2 (Patiala Rural,
Extion
Division(Railways): Sanor)
District/Region/Zone: Patiala Pin Code: 147001
Village: Patiala Pan No: N/A
Nearest Landmark: RK Property

Correspondence Address Details

Address: House no 98 State: Punjab


Rattan Nagar Sub-Division/Station/ Patiala-2 (Patiala Rural,
Extion Division(Railways): Sanor)
District/Region/Zone: Patiala Pin Code: 147001
Village: Patiala

Contact Details

Telephone No: N/A Fax: N/A


Mobile No: 9988720851 Email-ID: Ravinderbakshi82yah
Contact Person: Ravinder Bakshi [email protected]

Other Details

In case of New business – intended date of start: 06-03-2023


Source of Water Supply: Public
Sanction Electricity Load or HP Used: No

Page 1 of 3
Number of years applied for: 2

Detail(s) of Food Item

[Note:Only standardised food products are allowed to be manufactured as per the list available on FoSCoS.]

Other than Manufacturer Unit


Sl. No Name of the food category
1 15 - Ready-to-eat savouries
2 16 - Prepared Foods

Document(s) Details

S.No. Documents Description Uploaded Document


1 Identity Proof - Aadhar Card View
2 Photo - Aadhar Card View

Other Document(s) Details

S.No. Documents Description Uploaded Document


1 Proof of Premises view

S.No. Mode Of Payment Payment Date Transcation Number Razorpay ID Amount


1 Razorpay 01-03-2024 79709367199941 pay_Nh77LoeANPDVel 200.00

I/We declare that:


I/We have read,understood and shall abide all provisions of FSS Act,2006 and Rules, Regulations made
therein and orders issued from time to time applicable to declared food business.
I/We assure that articles of food mentioned in form satisfy the requirements of FSS Act 2006, Rules and
Regulations made thereunder.
I/We shall comply with the general hygiene and sanitary requirements as mentioned in the Schedule 4 of
the FSS (Licensing and Registration of Food Businesses) Regulations, 2011.
Expected Annual turnover of the food business is under Rs.12 Lacs. I will apply for License as and when
annual turnover of food businesses exceeds Rs. 12 Lacs.
I have read/understood the punishment provision under Section 61 of FOOD SAFETY AND STANDARDS ACT,
2006."61. Punishment for false information. If a person, in connection with a requirement or direction under
this Act, provides any information or produces any document that the person knows is false or misleading,
he shall be punishable with imprisonment for a term which may extend to three months and also with fine
which may extend to two lakh rupees"

I do hereby solemnly affirm and declare that all information and particulars furnished here by me are true and
correct to the best of my knowledge.

Declaration || Condition of License || Inspection Checklist

Page 2 of 3
घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची

Date & Time : N/A


Applicant Name : SamSim Kichen
Verified through Mobile :
IP Address :

Page 3 of 3

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