Food Safety Compliance System (FoSCoS)

https://foscos.fssai.gov.in
Form B
[See Regulation 2.1.2, Regulation 2.1.3, Regulation 2.1.7]

Application for Licenses / Renewal of license under food safety and Standards
Act,2006

Application Reference No: 20240722106259310 Application Type: New License

Name of Company/ HARI OM TRADERS Application Date: N/A
Organizations: Kind of Business: Repacker - Dairy units
GST No: Not Provided Trade/Retail - Retailer
Address: 52, MRS ROOHI Trade/Retail -
ROHIDAS PATRE, Wholesaler
MAPUSA, BARDEZ, CIN No: Not provided
CUNCHELIM, NORTH Port Name: N/A
GOA, GOA, Bardez,
North Goa ,
Goa-403507
PAN No: Not Provided

Registered Office Detail(s)

Address: 52, MRS ROOHI State: Goa

ROHIDAS PATRE, Pin Code: 403507
MAPUSA, BARDEZ,
CUNCHELIM,
NORTH GOA, GOA
District : North Goa

Address of Premises for which license is applied

Address: 52, MRS ROOHI State: Goa

ROHIDAS PATRE, Pin Code: 403507
MAPUSA, BARDEZ,
CUNCHELIM,
NORTH GOA, GOA
District : North Goa
Sub-Division : Bardez

Correspondence Address

Address: 52, MRS ROOHI State: Goa

ROHIDAS PATRE, Pin Code: 403507
MAPUSA, BARDEZ,
CUNCHELIM,
NORTH GOA, GOA
District : North Goa

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 Contact Information

Telephone No: N/A Fax: N/A

Mobile No: 8147906782 Email-ID: [email protected]
OM

Technically qualified person in charge of operations

Name: DADASAHEB Qualification: B.COM

PUNNAPPA KOLI Mobile No: 8147906782
Contact No: N/A Address: MAPUSA, BARDEZ,
Email-ID: AMUU1129@GMAI GOA
L.COM District: North Goa
State: Goa Photo Id Card: Aadhar Card
Pin Code: 403507
Photo ID Expiry Date: N/A
Photo ID No: 379290095408
FoSTaC No: N/A
Trainee Name: N/A
FoSTac Validity End Date: N/A

Person responsible for complying with conditions of License (The person must be same as mentioned
in Form IX, as per FSS Regulations, 2011)

Name: DADASAHEB Qualification: B.COM

PUNNAPPA KOLI Mobile No: 8147906782
Contact No: N/A Address: MAPUSA, BARDEZ,
Email-ID: AMUU1129@GMAI GOA
L.COM District: North Goa
State: Goa Photo Id Card: Aadhar Card
Pin Code: 403507
Photo ID Expiry Date: N/A
Photo ID No: 379290095408
Number of years applied for: 2

Kind Of Business: Manufacturer - Dairy units

Location and installed capacity of Milk Chilling Centers (MCC) / Bulk Milk Cooling Centers (BMCs)/ Milk
Processing Unit/ Milk Packaging Unit/Milk Collection Center in litres owned or managed by the applicant :

Sl.No. Name of MCC/ Address State District Postal Pin- Installed Capacity (in litres/
BMC Code day)
1 Milk Processing NORTH Goa North 403507 500
Unit GOA Goa

Average Quantity of milk per day to be used/handle (in litres) :

(A) In Lean Season : -
(B) In Flush Season : -

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Milk products to be manufactured and their manufacturing capacity:
Production Capacity (Tonnes / Year): 2.5

Sl.No. Food Category Sub-Food Product Kind of

Category Business
1 01 - Dairy products and analogues, 01.6 - Cheese and Chhana and Repacker -
excluding products of food category 2.0 analogues Paneer [01.6.1] Dairy units

Kind Of Business: Trade/Retail - Wholesaler

Sl.No. Food Product Category

1 01 - Dairy products and analogues, excluding products of food category 2.0

Kind Of Business: Trade/Retail - Retailer

Sl.No. Food Product Category

1 01 - Dairy products and analogues, excluding products of food category 2.0

Other Detail(s)

Whether Unit is Equipped with an analytical laboratory ? :No

Already Holding License: No
Other License: No

Is Holding PA/NOC: No

Document(s) Details

S.No. Documents Submission Document

Type Uploaded/
FBO Remarks
1 Blueprint/layout plan of the processing unit showing the dimensions Mandatory view
in metres/square metres and operation-wise area allocation * View
Sample Document
2 List of Directors/ Partners/ Proprietor/ ExecutiveMembers of Society/ Mandatory view
Trust with full address and contact details with nomination of
authorized signatory * View Sample Document
3 Name and List of Equipments and Machinery along with the number, Mandatory view
installed capacity and horsepower used * View Sample Document
4 Analysis report(Chemical & Bacteriological)of water to be used as N/A N/A
ingredient in food from a recognized/ public health laboratory to
confirm the potability indicating the name of authorized
representative of Lab who collected the sample and date of collecting
sample. (Not Applicable if water is not being used as ingredient)
View Sample Document,
5 Photo I.D and address proof issued by Government authority of Mandatory view
Proprietor/ Partner/ Director(s)/ Authorised Signatory. View Sample
Document
6 Proof of possession of premises. (Sale deed/ Rent agreement/ Mandatory view
Electricity bill, etc.) View Sample Document
7 Partnership Deed/ Self Declaration for Proprietorship/ Memorandum Mandatory view

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 S.No. Documents Submission Document
Type Uploaded/
FBO Remarks
& Articles of Association towards the constitution of the firm / Copy
of certificate obtained under Coop Act-1861/ Multi State Coop
Act-2002 in case of Cooperative View Sample Document
8 Form IX: Nomination of Person as per Clause 2.5of FSS Rules, 2008 N/A N/A
(Not applicable in case of Proprietor) Click here to Download Sample
Document in English | Click here to Download Sample Document in
Hindi *
9 Recall Plan * View Sample Document Mandatory view
10 Production unit photographs View Sample Document Mandatory view
11 Source or procurement plan for milk * View Sample Document Mandatory view

Other Document(s) Details

S.No. Documents Description Document Uploaded/FBO Remarks

1 NOC From Manufacturer Repacker Repackager view
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 have food safety plan to ensure that articles of food mentioned in form satisfy the requirements of FSS
Act 2006 and Rules and Regulations made thereunder.
Our facility 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.
I/We shall abide with all conditions of License.
Expected capacity of the business is to the best of my knowledge. I/We will modify our License as and when
our eligibility in the mentioned criteria for License changes.
I will be responsible for Permissions/No Objection Certificates from other Govt. bodies wherever required.
In case of manufacturing, the endorsed products refer to products for which standards are prescribed as
per FSS (Food Products and Additives) Regulations and FSS (Health Supplements, Nutraceuticals, Food for
Special Dietary Use, for Special Medical Purpose, Functional Food and Novel Food) Regulations, 2016 and
FSS (Approval for Non-Specific Food and Food Ingredients) Regulation, 2017 and FSS (Alcoholic Beverages)
Regulation, 2018. Only products as per above mentioned FSS regulations are allowed to be manufactured.
In case of repacking of food articles, the food items shall be brought/transported to our unit under hygienic
conditions with proper bulk packaging while maintaining the required special storage/transport conditions.
I shall manufacture only Standardised Products, its types and sub-types as per FSS (Food Products and
Additives) Regulations, 2011. In case of any deviation in ingredients or additives of the endorsed food
products, I will get my license modified under suitable category before manufacturing of such food products
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.

Declaration || Condition of License || Inspection Checklist

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घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची

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