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Date:11/29/2021 18:44:02
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Please review the registration.
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Created Date Created by

2021-11-29 17:11:17.0 tra38437

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Registration Expiration Date Registration Renewed Date
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2022-12-31
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Last Modified by
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FMLS

Last Updated
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2021-11-29

Last Modified by Company Registration Status

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IMPEMI S.A. VALID
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Is this facility engaged in the manufacturing/processing, packing, or holding of food for human or animal consumption in the United States?
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¤Yes ¡No
Section 1: Type of Registration
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Facility Location: Foreign Registration
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Initial Registration 11762782088 Pin No 2FF7G9eG

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Are you the new owner of a previously registered facility?
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¡Yes ¤No
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Previous Owner's Title:
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Previous Owner's Name:
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Previous Owner's Registration Number: y

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Section 2: Facility Name/Address Information
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Facility Name Telephone Number

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IMPEMI S.A. 593 9 99450677
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Facility Name Suffix Fax Number

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Company 593 9 99450677

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Facility Street Address, Line 1 E-Mail Address
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KM 9 1/2 VIA MONTECRISTI RIO CANA [email protected]

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Facility Street Address, Line 2 Unique Facility Identifier (UFI)

EDIF. WORLD TRADE CENTER TORRE A PISO 13 - OFICINAS DE PRO 886812990

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City
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MONTECRISTI
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State/Province/Territory
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Manabi
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Zip Code (Postal Code)

130902
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ECUADOR
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Section 3: Preferred Mailing Address Information
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Complete this section if different from Section 2 Facility Name/Address Information (OPTIONAL)
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Is the preferred mailing address the same as the facility address (Section 2)? Yes
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Name Telephone Number
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IMPEMI S.A. 593 9 99450677
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Address, Line 1 Fax Number

KM 9 1/2 VIA MONTECRISTI RIO CANA 593 9 99450677

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Address, Line 2 E-Mail Address
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EDIF. WORLD TRADE CENTER TORRE A PISO 13 - OFICINAS DE PRO [email protected]

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City
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MONTECRISTI

State/Province/Territory
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Manabi
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Zip Code (Postal Code)
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130902
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ECUADOR
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Section 4: Parent Company Name/Address Information
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(If applicable and if different from Sections 2 and 3). If information is the same as another section, check which section:
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¤Same as Facility Address (Section 2)
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¡Same as Preferred Mailing Address (Section 3)
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¡None of the above
Company Name Telephone Number
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IMPEMI S.A. 593 9 99450677

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Company Name Suffix Fax Number

Company 593 9 99450677

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Address, Line 1 E-Mail Address

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KM 9 1/2 VIA MONTECRISTI RIO CANA [email protected]

Address, Line 2
on

EDIF. WORLD TRADE CENTER TORRE A PISO 13 - OFICINAS DE PRO

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City
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MONTECRISTI
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State/Province/Territory
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Manabi
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Zip Code (Postal Code)

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130902
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ECUADOR
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Section 5: Facility Emergency Contact Information
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If information is the same as another section, check which section:
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¡Same as Facility Address (Section 2)
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¤Same as U.S. Agent Information (Section 7)
¡None of the above
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Individual's Title (Optional) Emergency Contact Phone
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001 786 3299154

Individual's Name (Optional) E-Mail Address

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MANUEL ECHEVERRIA [email protected]
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Individual's Middle Name (Optional) Job Title (Optional)
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Individual's Last Name (Optional)
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Section 6: Trade Names
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(If this facility uses trade names other than that listed in Section 2 above, list them below (e.g., "Also doing business as," "Facility also known as"))
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Are there alternate trade names used by your facility in addition to the name provided in Section 2: Facility Name/Address Information?

¤Yes
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¡No
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Alternate Trade Name #1: PITAREY
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Alternate Trade Name #2: HACIENDA CHOKOLYTOS

Section 7: United States Agent

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(To be completed by facilities located outside any state or territory of the United States, District of Columbia, or The Commonwealth of Puerto Rico)

Name Telephone Number

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MANUEL ECHEVERRIA 786 3299154 null

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Address, Line 1 Emergency Contact Phone

8510 Nw 72nd St 786 3299154

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Address, Line 2 City

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Miami

E-Mail Address State/Province/Territory

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[email protected] Florida
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Zip Code (Postal Code)

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33166
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UNITED STATES
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Section 8: Seasonal Facility Dates of Operation (Optional)

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Give the approximate dates that your facility is open for business, if its operations are on a seasonal basis (Optional).

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Harvest 1
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Start Month End Month
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January
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December

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Harvest 2
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Start Month End Month
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Section 9: General Product Categories - Human/Animal/Both
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þFood for Human Consumption ¨Food for Animal Consumption
Section 9a: General Product Categories - Food for Human Consumption; and Type of Activity Conducted at the
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Facility
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To be completed by Ambient Food Refrigerated Food Frozen Food Acidified Low- Interstat Contract Labeler / Manufact Packer / Salvage Farm Other
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all food facilities. Storage Warehouse Storage Warehouse Storage Warehouse Food Acid e Sterilizer Relabele urer / Repacke Operator Mixed- Activity
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Please see / Holding Facility / Holding Facility / Holding Facility Process Food Conveya r Process r (Recondi Type Conduct

instructions for (e.g., storage (e.g., storage (e.g., storage or Process nce or tioner) Facility ed

further examples. IF facilities, including facilities, including facilities) or Caterer / (Please

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NONE OF THE storage tanks, grain storage tanks) Catering Specify)

MANDATORY elevators) Point

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CATEGORIES
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BELOW APPLY,
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SELECT BOX 37
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17.FRUIT AND FRUIT PRODUCTS[21 CFR 170.3 (n) (16), (27), (28), (35), (43)]
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a.Fresh Cut Produce ¨ ¨ þ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨
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b.Raw Agricultural
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¨ ¨ þ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨ ¨
Commodities
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Section 10: Owner, Operator, or Agent-in-Charge Information
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Provide the following information, if different from all other sections on the form. If information is the same as another section of the form, check which
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section:
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If information is the same as Section 2, check the box:

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¤Section 2 - Facility Address Information
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¡Section 3 - Preferred Mailing Address Information

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¡Section 4 - Parent Company Address Information

¡Section 7 - US Agent Address Information
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¡None of the above

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Name of Entity or Individual Who is the Owner, Operator, or Agent-in-Charge: MAIGUA PORTILLA EDISON ROBERTO
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Address, Line 1 Telephone Number

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KM 9 1/2 VIA MONTECRISTI RIO CANA 593 9 99450677

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Address, Line 2 Fax Number

EDIF. WORLD TRADE CENTER TORRE A PISO 13 - OFICINAS DE PRO 593 9 99450677
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City E-Mail Address

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MONTECRISTI [email protected]
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State/Province/Territory

Manabi
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Zip Code (Postal Code)
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130902
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ECUADOR
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Section 11: Inspection Statement
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þFDA will be permitted to inspect the facility at the time and in the manner permitted by the Federal Food, Drug, and Cosmetic Act.
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Section 12: Certification Statement

The owner, operator, or agent-in-charge of the facility, or an individual authorized by the owner, operator, or agent-in-charge of the facility, must
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submit this form. By submitting this form to FDA, or by authorizing an individual to submit this form to FDA, the owner, operator, or agent-in-charge of the
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facility certifies that the above information is true and accurate. An individual (other than the owner, operator or agent-in-charge of the facility) who submits

the form to the FDA also certifies that the above information submitted is true and accurate and that he/she is authorized to submit the registration on the
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facility's behalf. An individual authorized by the owner, operator, or agent-in-charge must below identify by name the individual who authorized submission
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of the registration. Under 18 U.S.C 1001, anyone who makes a materially false, fictitious, or fraudulent statement to the U.S. Government is subject to
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criminal penalties.
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NAME OF PERSON SUBMITTING THIS REGISTRATION FORM: MAIGUA PORTILLA EDISON ROBERTO
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CHECK ONE BOX
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¤A. INDIVIDUAL ASSOCIATED WITH THE INFORMATION IN SECTION 10 (STOP HERE, FORM IS COMPLETED)
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¡B. ANOTHER AUTHORIZED INDIVIDUAL
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Address Information for the Authorizing Individual:
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Individual's Name Telephone Number
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-N/A- -N/A-

Address, Line 1 Fax Number

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-N/A- -N/A-
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Address, Line 2 E-Mail Address

-N/A- -N/A-
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City
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State/Province/Territory
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Zip Code (Postal Code)

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-N/A-
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Country/Area
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-N/A-
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