.'--- v":~~.:.

. Mobile No.:-,-------,..----------, '-....;,.,.-,-----~-..,..

FAx·No~:. · Emailr.: .' .' '. ....... .[.v()le~·lncasefhe numbertsiare aPhor.commonnumberts}, plea!fespe~ify .

the nam,eofthe contact.person aswellJ .' .. . ..(e) Area orLocation wherefood'businessis tobe conducted/ . .

Address ofthe premises: .

_..~j.c.~,

. ' - . ~-

......' ..... ~~:~'C~_ .Quantity·inKg.pe·tBVsiitwr~~~,J~

~tl per annum. c.

S.No. ' .: NomeofFoodCategory' ..•.

(fjDescriptionofthe food items proposed 'to be Manufactured or ....Sold:

,.' ...

"

.. ,.'

_---.-------...,..--,--------~-------,--,-----,----,--------c --,

I

I

I

. ...

(gjTotal Annual turnoverfrom the food business, if existing, along ,, with any supporting documenttsjshowingproofof income (*in case'ofrenewal):' , '

r::-'"'C,

(h) In caseofnewbusiness> intendeddate ofstart:

(i) Incase 'of seasonal business-state theopeningandclosingperiod '°fthe year:_~_.,.:--.,..;..,----'--c'--:--'-------""---'- ---,-'-_",,",-

,(0) Source ofwater supply:"~:'rPuBli:C-supplY>'~~~:' "Private supply , .Any other source(kjWhetheranyelectric poweris'used in-manufacture ofthe food

,':,~-;::;:~ite\l\S::": ' ':"-il'~ . "

. D,:YesD", , 'N''0," -- '~""'o"~• _.': ". ;: '..~,.:~ .;.:. c-:;

~-" ;;..' ..""'--~'" '~

~~~~lf:yes,please>Sf4te;the exactHP~used or sanctioned'Electricityload:

(1) I/We have-forwarded a sum ofRs...... .. .•...•....... ',' .....; ....towardsregistration fees'according tothe'pro~isionofthe FoodSafety arid "Standards(LicensingandRegistration) Regulations, 201 1vide:'

"Dpemarid,DraftNo,~ (payable to . .)o . Cash

C,_

., Printed by : The Manager. GovtPress, portBlair.

"

....{Signatureofthe Applicant}

....---------------------------_.-~--

, (d) Correspondence address:·

Tel No.: Mobile No.:'----_.,.:..-__-c-

FAXN0.: Email:_..-,-~--..,-_---'-c- ---,-C-~

[.vote:' Incasethenumber(s) are aPhor commonnumber(s), please specifythe nameofthecontaCtpersonasWell] . . •. .. .(e) Area or Location where.food business is to be conducted!

Address of the premises: .

____~---C,~-----~"""'. ~-~ . .(t) Description of the food items proposed to be Manufactured orSold: . .

S.No. . ~omeof Food Cotegory .

Please attach se]Jar~tesheet, 'if.required

(Juontityin Kg.peraiv~1:,"i;i);S:),~MJ. per onnum

J--

Declaration

Dated:

(Signature)

MGPPB-31jMedicalj2011-12,OOO Nos. (SB-Hj::L-XlIl)

Annexure-I.

Form 'B'[See Regulation 2.1.2, Regulation 2.1.3 and Regulation 2.1.7]

Application for License / Renewal ofLicense under Food Safetyand Standards Act, 2006

Kind of business (Please tick more than one, if applicable):

o ManufacturingIProcessing including sorting, grading etc.o Milk Collection/Chillingo Slaughter Houseo Solvent extracting unito Solvent extracting plant equipped with pre-cleaning of oil

seeds or pre-expelling of oil .o Solvent extracting and oil refining planto PackagingORe-labelling (manufactured by third party under own

packing and labelling)o Importingo StoragefWarehouse/Cold Storageo Retail Tradeo Wholesale Tradeo Distributor/Suppliero Transporter of Foodo Cateringo Dhaba or any other food vending establishmento Club /Canteeno Hotelo Restauranto Other(s), please specify: _

1. Name of the Company/Organization: _-.,- _

2. Registered Office Address: -,--__

3. Address of premise for which license is being applied

4. Name and/or designation, qualification and address of technicallyqualified person in charge of operations as required underRegulation .....

Name:

Qualification:

Address:

Telephone Number(s):

Email:

Mobile No .:

v

Photo Identity Card No. and expiry date:

5. Name and/or designation, address and contact details of personresponsible for complying with conditions of license (if differentfrom 4 above):

Name:

Address:

•.

Telephone Number(s):

Email:

Mobile No.: \

Photo Identity Card No. and expiry date:

6. Correspondence address (if different from 3 above)

,/

7. Tel. No.: Mobile 0.:- - --- - - - ---

FAX No.: Email:--- - - - - ---------

8. Food items proposed to be manufactured:

S.No. Name of Food Item auantity in Kg. per day orM.T. per annum

If required attach separate sheet.If already having valid license- mention annual quantity of each food

category manufactured during last three years.

9. Installed capacity food product-wise (per clay).

•

10. For Dairy Units

(i) Location and installed capacity of Milk Chilling Centers (MCC) /Bulk Milk Cooling Centers (BMCs)/ Milk Processing Unit! MilkPackaging Unit in litres owned or managed by the applicant.

S.No. Name of Food Item Quantity in Kg. per day or M.T. per annum

•

If required attach separate sheet

(ii) Average quantity of milk per day to be used/handled ina. in lean season ,

b. in flush season(iii) Milk products to be manufactured and their manufacturing

capacity (tones/year)1)........ ..... . ... .2)............. .. ...3) ..................

11. For Solvent -Extracted Oil, De Oiled Meal and Edible Flour:

(i) Details of proposed business ,Name From • Solvent -Extracted Oil, De Oiled Meal and Edible Vegetable 'of oil seed Flourbearing or nut

Crude Neutralized Neutralized Refmed De Ediblematerial or & bleached meal Oiled Flour

cake

If already having valid license- mention annual quantity of eacproduct manufactured during last three years . .

•

ii) arne and address of factory or factories used by the miller orsolvent extractor for processing oil bearing material produced orprocured by him or for refining solvent Extracted Oil produced by

him.

12. Sanctioned electricity load or HP to be used _

13. Whether unit is equipped with an analytical laboratory _

If yes, the details thereof : _

14. In case of renewal or transfer of license granted under other lawsas per 'proviso to Regulation 5(1) - period for which licenserequired ( 1 to 5 years) _

15. I/We have forwarded a sum of Rs. towards Licensefees according to the provision of the Food Safety and StandardsRegulations, 2011 vide:

Demand Draft No. (payable to )

(Signature of the applicant/authorized signatory)

I

MGPPB-30/Medical/2011-3.000 Nos . (SB-HCL-XIIIj '

Annexure-I.•

Declaration•

I, Mr.lMs.lMrs. S/o / D/o/W/0

Mr. , Rio _

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. I further declare that the food business conducted

or proposed to be conducted by/through me conforms/shall

conform to the Food Safety and Standards Act, Regulations/ Bye­

laws enacted thereunder, and specifically to the Guidel ines on

Hygiene and Sanitary Practices provided under Schedule-4 of the

Registration and Licensing Regulations published by the Food

Safety and Standards Authority of India or any person authorized

on its behalf from time to time.

Dated:

(Signature)

Annexure-2

Documents to be enclosed for new application for license toState/Central Licensing Authority

I. Fonn-B duly compl eted and signed (in dupl icate) by the proprietor/partner or the authorised signatory.

2. Blueprint/layout plan of the processing unit showing the dimensions inmetres/square metres and operation-wise area allocation.

3. List of Directors with full address and contact details .

4. Name and List of Equipments and Machinery alongwith the number,installed capacity and horse power used .

5. Photo 1.0. and address proof issued· by Government authori ty ofProprietor/Partn erlDirector(s)/Authorised Signatory.

6. List of food category desired to be manufactured. (In case ofmanufacturers).

7. Authority letter with name and address of responsible personnominated by the manufacturer alongwith alternative responsibleperson indicating the powers vested with them viz assisting the officersin inspections, collection of samples, packing and dispatch.

8. Analysis rcportjChemical and Bacteriological) of water to be used asingredient in food from a recognized! publ ic health laboratory toconfirm the portability indicating the name of authorized representativeof Lab . who collected the sample and date. of collecting sample .

9. Proof of possession of premises. (Sale deed! Rent agreement! Electricitybill, etc .)

10. Partnership Deed/Affidavit/Memorandum & Articles of Associationtowards the constitution of the finn.

II. Copy of certificate obtained under Co-op Act - I86 1!Multi State Co-opAct - 2002 in case of Co-operatives.

12. NOC from manufacturer in case of Re-labellers,

15. Source of raw material for meat and meat processing plants .

16. Pesticide residues report of water to be used as ingredient in case ofunits manufacturing packaged drinking water, packaged Mineral waterand!or carbonated water from a recognised! public health laboratoryindicating the name of authorised representative of Lab. who collectedthe sample and date of collecting sample, including source of raw waterand treatment plan .

17. Recall plan wherever applicable, with details on whom the product isdistributed.

18. NOCs from Municipality or local body and from State PollutionControl Board except in case of notified industrial area.

Documents to be included for renewal or transfer of license givenunder other existing laws prior to these Regulations

I . Any change in documents or information provided during grant ofprevious license.

~ .Certificate or Plan of Food Safety Management System being adopted(for units under Central Licensing it has to be a certificate fromaccredited agencies).

3. List of workers with their Medical Fitness Certificates.

4. Name, qualification and details of technical personnel in charge of

operation.

MGPPB-3 1/Medicalj2011-12,OOO Nos . (SB-HCL-XIIIJ

•