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FORM 'A'
[See Regulation 2.1.1 (assets/docs/2.1.1.pdf) and Regulation 2.1.7 (assets/docs/2.1.7.pdf)]

Application for Registration under Food Safety and Standards Act, 2006

Application No : 30240725117149284 Registration No : 22724882000091

Name of Applicant / Company : TASABBAR S/O RAHISUDDIN Designation : Proprieter

Kind of Business : Food Services - Food Vending Establishment Expiry Date: 27-07-2025

Address of Premises where food business is located

Address : LUCKY JUICE, PURANA BAZAR, HAPUR State : Uttar Pradesh

Sub-Division/Station/Division(Railways) : NAGAR PALIKA HAPUR ZONE

District/Region/Zone : Hapur
2

Village : GADDAPADA Pin Code : 245101

Correspondence Address Details

Address : 942, KOTLA MEWATIYAN, HAPUR State : Uttar Pradesh

Sub-Division/Station/Division(Railways) : NAGAR PALIKA HAPUR ZONE

District/Region/Zone : Hapur
2

Village : KOTLA MEWATIYAAN Pin Code : 245101

Contact Details

Telephone No. : NA Fax : NA

Mobile No : 8430733717 Email-ID : NA

Contact Person : TASABBAR

Other Details

In case of New business – intended date of start : NA

In case of Sessional business, State the opening and closing period of the year : NA - NA

Source of Water Supply : N/A

Sanction Electricity Load or HP Used : No

Description of the food items proposed to be manufactured or sold

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

Other then Manufacturer Unit

Sl. No. Name of the food category

1 14 - Beverages, excluding dairy products

Submitted Document(s):

S.No. Documents Description Uploaded Document

View (/gateway/dms/document-
1 Photo view/foscos6/2024/07/25/1b5bcf58-0a23-42a9-8787-
fda901c798a8.jpg)

View (/gateway/dms/document-
2 Identity Proof - Aadhar Card view/foscos6/2024/07/25/521a4a1d-5538-4201-9e0f-
c9bb481dac99.pdf)

Other Document

Note:
1. Upload State specific documents in this section. (View Mandatory Documents)
2. Maximum of 15 documents can be uploaded, if you have documents more than 15 then please merge your documents and upload it.
3.You have uploaded 0 out of 15 documents.

Sl. No. Document Description Upload Document(s) (Max File Size:5MB,type:pdf,jpeg,jpg,png)

Choose file No file chosen

Select
Upload

No. of years you want to apply for : 1

I 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/We have complied with all the permissions/rules, which are applicable to my food business and the premises of the food business such as
CGWA NOC etc
I/We do not possess more than one active license/registration for any other food business(es) at the same premises.
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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