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: 30240301115916582 Application Type: Renewal
Name of Applicant / SamSim Kichen Application Date: 01-03-2024
Company: Kind of Business: Food Services -
Designation: Individual Restaurants, Food
Expiry Date: 07-03-2026 Services - Food
Vending
Establishment, Food
Services - Petty
Retailer of snacks/tea
shops
Certificate No: 22123682000105
Address of Premises Where Food Business Is Located
Address: House no 98 State: Punjab
Rattan Nagar
Sub-Division/Station/ Patiala-2 (Patiala Rural,
Extion
Division(Railways): Sanor)
District/Region/Zone: Patiala Pin Code: 147001
Village: Patiala Pan No: N/A
Nearest Landmark: RK Property
Correspondence Address Details
Address: House no 98 State: Punjab
Rattan Nagar Sub-Division/Station/ Patiala-2 (Patiala Rural,
Extion Division(Railways): Sanor)
District/Region/Zone: Patiala Pin Code: 147001
Village: Patiala
Contact Details
Telephone No: N/A Fax: N/A
Mobile No: 9988720851 Email-ID: Ravinderbakshi82yah
Contact Person: Ravinder Bakshi oo@gmail.com
Other Details
In case of New business – intended date of start: 06-03-2023
Source of Water Supply: Public
Sanction Electricity Load or HP Used: No
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Number of years applied for: 2
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 15 - Ready-to-eat savouries
2 16 - Prepared Foods
Document(s) Details
S.No. Documents Description Uploaded Document
1 Identity Proof - Aadhar Card View
2 Photo - Aadhar Card View
Other Document(s) Details
S.No. Documents Description Uploaded Document
1 Proof of Premises view
S.No. Mode Of Payment Payment Date Transcation Number Razorpay ID Amount
1 Razorpay 01-03-2024 79709367199941 pay_Nh77LoeANPDVel 200.00
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. Punishment 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 punishable with imprisonment for a term which may extend to three months and also with fine
which may extend to two 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
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घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची
Date & Time : N/A
Applicant Name : SamSim Kichen
Verified through Mobile :
IP Address :
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