Form "A"

[See Regula on 2.1.1 and Regula on 2.1.7

Application for Registration under Food Safety and Standards Act, 2006
Applica on No: 30200108101638500
Name of Applicant / Company : M/S Shah Chhotalal And Sons Fruit Juice Kiosk
Food vending establishment
Kind of Business :
Pe y Retailer of snacks/tea shops
Designa on : Partner
Address of Premises where food business is located Correspondence Address Details

Pla orm No- West in Circula ng Area , Virar, 301/302 Shri Annapurna Apt., Near Desai
Virar Rly. Stn. (Near PRS) West in Circula ng Address : Hospital Opp. Suman Complex , Agashi Road,
Area, (W R), Virar West 40130
Address :
Mumbai, State : Maharashtra
Western Railway ,
District/Region/Zone : Vasai Tahashil (Thane Zone-6)
Maharashtra, Pin- 401303
Sub-
State : Maharashtra
Division/Sta on/Division : Vasai Tahashil
District/Region/Zone : Western Railway (Railways)
Sub- Village : N/A
Division/Sta on/Division : Mumbai
Pin Code : 401303
(Railways)
Village : N/A
Pin Code : 401303

Contact Details

Tel No : NA Mobile No : 9699301708

Fax No : NA Email : vikas.shah12@gmail.com
Contact Person : NA
Other Details
In case of New business – intended date of start : Chotelal a
In case of Sessional business, State the opening and closing period of the
NA -NA
year :
Source of Water Supply : Other(s) - By Railway
Sanc on Electricity Load or HP Used : 2
Upload Photo : 2019/2/RGPHID30190209143333490.jpg
Upload Document for Iden ty Proof Aadhaar Card
(eg: Ra on Card, Voter ID Card etc.) 2019/2/RGID30190209143333490.pdf
Descrip on of the food items proposed to be manufactured or sold:
Sl. No. Name of the food category
1 14 - Beverages, excluding dairy products
2 16 - Prepared Foods
3 15 - Ready-to-eat savouries

Submi ed Document(s):
Sl. No. Document Description Uploaded Document
1 Health NOC 2019/2/30190209143333490_3133_20022019104945.pdf
2 Any Other Document 2019/2/30190209143333490_1040_18022019013026.pdf
3 Declara on Form 2019/2/30190209143333490_3001_09022019025212.pdf

Place :
____________________
Date : (Signature of the Applicant)