Food Safety Compliance System
Form A
[See Regulation 2.1.1, Regulation 2.1.7]
Application for Registration under food safety and Standards Act,2006
Application No: Application Type: New Registration
Name of Applicant / PRINCE BHAKAT C/O Application Date: N/A
Company: PRINCE DIGITAL Kind of Business: Trade/Retail - Retailer
Designation: Individual
Address of Premises Where Food Business Is Located
Address: VILLAGE PICHHLI State: Jharkhand
District/Region/Zone: Purbi Singhbhum Sub-Division/Station/ Potka
Village: Pichli Division:
Pin Code: 832107 Pan No: HIDPB7196A
Nearest Landmark: N/A Name: PRINCE BHAKAT
DOB: 01-07-2005
Gender: MALE
Correspondence Address Details
Address: VILLAGE PICHHLI State: Jharkhand
District/Region/Zone: Purbi Singhbhum Sub-Division/Station/ Potka
Village: Pichli Division:
Pin Code: 832107
Contact Details
Telephone No: N/A Fax: N/A
Mobile No: 6299408422 Email-ID: princebhakat809@gma
Contact Person: PRINCE BHAKAT [Link]
Aadhaar No: 94XXXXXXXX58
Other Details
In case of New business – intended date of start: N/A
Source of Water Supply: N/A
Sanction Electricity Load or HP Used: No
Number of years applied for: 1
Detail(s) of Food Item
[Note:Only standardised food products are allowed to be manufactured as per the list available on FoSCoS.]
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Other than Manufacturer Unit
Sl. Name of the food category
No
1 05 - Confectionery
2 04 - Fruits and vegetables (including mushrooms and fungi, roots and tubers, fresh pulses and
legumes, and aloe vera), seaweeds, and nuts and seeds
3 06 - Cereals and cereal products, derived from cereal grains, from roots and tubers, pulses, legumes
and pith or soft core of palm tree, excluding bakery wares of food category 7.0
4 07 - Bakery products
5 10 - Eggs and egg products
6 12 - Salts, spices, soups, sauces, salads and protein products
7 14 - Beverages, excluding dairy products
8 15 - Ready-to-eat savouries
Document(s) Details
[Link]. Documents Description Uploaded Document
1 Identity Proof - Aadhar Card
2 Photo
Other Document(s) Details
[Link]. Documents Description Uploaded Document
1 Proof of Premises
2 paper
3 pan
4 registration
5 Photographs of the unit (Entrance/Front facing end of the unit)
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. Penalty 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 liable to penalty which may extend to ten 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.
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Declaration || Condition of License || Inspection Checklist
घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची
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