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: 30250626120526118 Application Type: New Registration
Name of Applicant / PR MUSHROOM Application Date: 26-06-2025
Company: Kind of Business: Trade/Retail -
Designation: Individual Wholesaler
Address of Premises Where Food Business Is Located
Address: OPP SAI MANDIR State: Maharashtra
CIVIL LINE ROAD
Sub-Division/Station/ Chandrapur
CHANDRAPUR
Division(Railways):
District/Region/Zone: Chandrapur Pan No: CQSPN2508Q
Village: Chandrapur (M Cl) Name: RAKHI SANJAY
Pin Code: 442401 NIRANJANE
Nearest Landmark: SAI MANDIR DOB: 07-09-1997
Gender: FEMALE
Correspondence Address Details
Address: WARD NO.5 NEAR State: Maharashtra
MAI APPT Sub-Division/Station/ Chandrapur
GADCHANDUR Division(Railways):
District/Region/Zone: Chandrapur Pin Code: 442908
Village: Chandur
Contact Details
Telephone No: N/A Fax: N/A
Mobile No: 9322418502 Email-ID: niranjanerakhi@gmail
Contact Person: RAKHI SANJAY .com
NIRANJANE Aadhaar No: 22XXXXXXXX29
Other Details
In case of New business – intended date of start: 01-07-2025
Source of Water Supply: Private
Sanction Electricity Load or HP Used: No
Number of years applied for: 5
Detail(s) of Food Item
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[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 99 - Substances added to food
Document(s) Details
S.No. Documents Description Uploaded Document
1 Identity Proof - Aadhar Card View
2 Photo View
Other Document(s) Details
S.No. Documents Description Uploaded Document
1 Proof of Premises view
2 adhar view
S.No. Mode Of Payment Payment Date Transcation Number Razorpay ID Amount
1 Razorpay 26-06-2025 2836130041213708 pay_QloopmdLFBdU08 500.00
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. 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.
Declaration || Condition of License || Inspection Checklist
घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची
Date & Time : 26-06-2025 17:36:33 IST
Applicant Name : PR MUSHROOM
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Verified through Mobile : 93XXXXXX02
IP Address : 43.251.75.170
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