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: 30250914121483703 Application Type: Renewal
Name of Applicant / Vibhu Tripathi Application Date: 14-09-2025
Company: Kind of Business: Food Services -
Designation: Individual Restaurants
Expiry Date: 15-09-2026 Certificate No: 22723621000478
Address of Premises Where Food Business Is Located
Address: Hiatus Cafe, H.P. State: Uttar Pradesh
Dubey Marg
Sub-Division/Station/ Zone No-2
Daudpur,
Division(Railways):
Gorakhpur. UP,
273001 Pan No: BGVPT8631G
Name: VIBHU TRIPATHI
District/Region/Zone: Gorakhpur
DOB: 07-06-1999
Village: Betiahata
Gender: MALE
Pin Code: 273001
Nearest Landmark: N/A
Correspondence Address Details
Address: S/o Bhupendra State: Uttar Pradesh
Nath Tripathi, 574, Sub-Division/Station/ Gorakhpur Tahsil
Mohaddipur, Division(Railways):
Khorabar urf
Pin Code: 273001
SoobaBazar,
Gorakhpur, 273008
District/Region/Zone: Gorakhpur
Village: Gorakhpur (M
Corp.)
Contact Details
Telephone No: N/A Fax: N/A
Mobile No: 8299235280 Email-ID: N/A
Contact Person: 8299352609 Aadhaar No: 65XXXXXXXX83
Other Details
In case of New business – intended date of start: N/A
Source of Water Supply: Private
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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.]
Other than Manufacturer Unit
Sl. No Name of the food category
1 16 - Prepared Foods
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
No Record Found
S.No. Mode Of Payment Payment Date Transcation Number Razorpay ID Amount
1 Razorpay 14-09-2025 1003286391072160 pay_RHQ7s8OfPMtOPe 100.00
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
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Date & Time : 14-09-2025 14:15:20 IST
Applicant Name : Vibhu Tripathi
Verified through Mobile : 82XXXXXX80
IP Address : 223.233.65.218
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