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: 20240313105762029 Application Type: New License

Name of Company/ BANSAL GRAH Application Date: N/A
Organizations: UDHYOG Kind of Business: Repacker - General
GST No: Not Provided Manufacturing
Address: 5 B/80 KRISHNA Trade/Retail -
NAGAR SHAHGANJ Wholesaler
BODLA ROAD AGRA, Trade/Retail - Retailer
Nagar Nigam Food CIN No: Not provided
Safety Zone 06, Agra, Port Name: N/A
Uttar
Pradesh-282010
PAN No: Not Provided

Registered Office Detail(s)

Address: 5 B/80 KRISHNA State: Uttar Pradesh

NAGAR SHAHGANJ Pin Code: 282010
BODLA ROAD
AGRA
District : Agra

Address of Premises for which license is applied

Address: 5 B/80 KRISHNA State: Uttar Pradesh

NAGAR SHAHGANJ Pin Code: 282010
BODLA ROAD
AGRA
District : Agra
Sub-Division : Nagar Nigam Food
Safety Zone 06

Correspondence Address

Address: 5 B/80 KRISHNA State: Uttar Pradesh

NAGAR SHAHGANJ Pin Code: 282010
BODLA ROAD
AGRA
District : Agra

Page 1 of 11
Contact Information

Telephone No: N/A Fax: N/A

Mobile No: 8865009044 Email-ID: adityacse1996@gmail.
com

Technically qualified person in charge of operations

Name: MUNESH BANSAL Qualification: GRADUATE

Contact No: N/A Mobile No: 8865009044
Email-ID: adityacse1996@gm Address: 5 B/80 KRISHNA
ail.com NAGAR, KRISHNA
State: Uttar Pradesh NAGAR AGRA

Pin Code: 282010 District: Agra

Photo ID No: 319504692656 Photo Id Card: Aadhar Card

FoSTaC No: N/A Photo ID Expiry 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: MUNESH BANSAL Qualification: GRADUATE

Contact No: N/A Mobile No: 8865009044
Email-ID: adityacse1996@gm Address: 5 B/80 KRISHNA
ail.com NAGAR, KRISHNA
State: Uttar Pradesh NAGAR AGRA

Pin Code: 282010 District: Agra

Photo ID No: 319504692656 Photo Id Card: Aadhar Card

Number of years applied for: 5 Photo ID Expiry Date: N/A

Kind Of Business: Manufacturer - General Manufacturing

Production Capacity(MT / Day): 1

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

Category Business
1 06 - Cereals and cereal 06.1 - Whole, Bean [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
2 06 - Cereals and cereal 06.1 - Whole, Pearl Barley (Jau) [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares

Page 2 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
of food category 7.0
3 06 - Cereals and cereal 06.1 - Whole, Wheat [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
4 06 - Cereals and cereal 06.1 - Whole, Maize [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
5 06 - Cereals and cereal 06.1 - Whole, Any other foodgrains [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
6 06 - Cereals and cereal 06.1 - Whole, Unprocessed whole raw pulses (not Repacker -
products, derived from broken, or for direct human consumption) [06.1] General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
7 06 - Cereals and cereal 06.1 - Whole, Oats [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
8 06 - Cereals and cereal 06.1 - Whole, Quinoa [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
9 06 - Cereals and cereal 06.1 - Whole, Durum Wheat [06.1] Repacker -
products, derived from broken, or General

Page 3 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
10 06 - Cereals and cereal 06.1 - Whole, Basmati Rice [6.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
11 06 - Cereals and cereal 06.1 - Whole, Blended Rice [6.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
12 06 - Cereals and cereal 06.1 - Whole, Pulses (Lentil (Masur), Black gram Repacker -
products, derived from broken, or (Urd), Green gram (Moong), Bengal General
cereal grains, from roots flaked grain, gram (Chana or Chick pea) or Kabuli Manufacturing
and tubers, including rice chana or Chhole or(green chick pea)
pulses,legumes and pith hara chana, Red gram (Arhar), Horse
or soft core of palm tree, gram (Kulthi), Field bean (Black,
excluding bakery wares Brown, White), Sem, Peas dry (Matra),
of food category 7.0 Soybean, Rajmah or Double beans or
Broad beans or Black beans, Lobia or
black eyed beans or black eyed white
lobia, Moth bean (matki)) [06.1]
13 06 - Cereals and cereal 06.1 - Whole, Chia Seeds [6.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
14 06 - Cereals and cereal 06.1 - Whole, Millets [6.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
15 06 - Cereals and cereal 06.1 - Whole, Triticale [6.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing

Page 4 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
16 06 - Cereals and cereal 06.1 - Whole, Rice [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
17 06 - Cereals and cereal 06.1 - Whole, Soybean [06.1] Repacker -
products, derived from broken, or General
cereal grains, from roots flaked grain, Manufacturing
and tubers, including rice
pulses,legumes and pith
or soft core of palm tree,
excluding bakery wares
of food category 7.0
18 12 - Salts, spices, soups, 12.2 - Herbs, Caraway (Siahjira) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
19 12 - Salts, spices, soups, 12.2 - Herbs, Cardamom (Elaichi) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
20 12 - Salts, spices, soups, 12.2 - Herbs, Chillies and Capsicum (Lal Mirchi) Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
21 12 - Salts, spices, soups, 12.2 - Herbs, Cinnamon (Dalchini) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
22 12 - Salts, spices, soups, 12.2 - Herbs, Cassia (Taj) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
23 12 - Salts, spices, soups, 12.2 - Herbs, Cloves (Laung) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments

Page 5 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
24 12 - Salts, spices, soups, 12.2 - Herbs, Coriander (Dhania) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
25 12 - Salts, spices, soups, 12.2 - Herbs, Cumin (Zeera, Kalonji) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
26 12 - Salts, spices, soups, 12.2 - Herbs, Fennel (Saunf) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
27 12 - Salts, spices, soups, 12.2 - Herbs, Fenugreek (Methi) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
28 12 - Salts, spices, soups, 12.2 - Herbs, Dried Ginger (Sonth, Dried Adrak) Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
29 12 - Salts, spices, soups, 12.2 - Herbs, Mace (Jaipatri) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
30 12 - Salts, spices, soups, 12.2 - Herbs, Mustard (Rai, Sarson) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
31 12 - Salts, spices, soups, 12.2 - Herbs, Nutmeg (Jaiphal) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
32 12 - Salts, spices, soups, 12.2 - Herbs, Poppy (Khas Khas) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
33 12 - Salts, spices, soups, 12.2 - Herbs, Saffron (Kesar) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments

Page 6 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
34 12 - Salts, spices, soups, 12.2 - Herbs, Turmeric (Haldi) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
35 12 - Salts, spices, soups, 12.2 - Herbs, Curry Powder [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
36 12 - Salts, spices, soups, 12.2 - Herbs, Mixed Masala [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
37 12 - Salts, spices, soups, 12.2 - Herbs, Aniseed (Saunf) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
38 12 - Salts, spices, soups, 12.2 - Herbs, Ajowan (Bishops seed) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
39 12 - Salts, spices, soups, 12.2 - Herbs, Dried Mango Slices [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
40 12 - Salts, spices, soups, 12.2 - Herbs, Dried Mango Powder (Amchur) Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
41 12 - Salts, spices, soups, 12.2 - Herbs, Garlic (Lahsun) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
42 12 - Salts, spices, soups, 12.2 - Herbs, Celery [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
43 12 - Salts, spices, soups, 12.2 - Herbs, Dehydrated Onion (Sukha Pyaj) Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments

Page 7 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
44 12 - Salts, spices, soups, 12.2 - Herbs, Asafoetida (Hing or Hingra) [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
45 12 - Salts, spices, soups, 12.2 - Herbs, Harrisa (Red Hot Pepper Paste) Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
46 12 - Salts, spices, soups, 12.2 - Herbs, Seasoning [12.2.2] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
47 12 - Salts, spices, soups, 12.2 - Herbs, Dried Sweet Marjoram [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
48 12 - Salts, spices, soups, 12.2 - Herbs, TEJPAT [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
49 12 - Salts, spices, soups, 12.2 - Herbs, STAR ANISE [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
50 12 - Salts, spices, soups, 12.2 - Herbs, Dried Oregano [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
51 12 - Salts, spices, soups, 12.2 - Herbs, Pimento or Allspice [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
52 12 - Salts, spices, soups, 12.2 - Herbs, Dried Laurel or Dried Bay Leaf Repacker -
sauces, salads and spices, [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
53 12 - Salts, spices, soups, 12.2 - Herbs, Dried Mint [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments

Page 8 of 11
Sl.No. Food Category Sub-Food Product Kind of
Category Business
54 12 - Salts, spices, soups, 12.2 - Herbs, Dried Rosemary [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
55 12 - Salts, spices, soups, 12.2 - Herbs, DRIED THYME [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
56 12 - Salts, spices, soups, 12.2 - Herbs, DRIED SAGE [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments
57 12 - Salts, spices, soups, 12.2 - Herbs, BLACK, WHITE & GREEN (BWG) Repacker -
sauces, salads and spices, PEPPERS [12.2.1] General
protein products seasonings, Manufacturing
and
condiments
58 12 - Salts, spices, soups, 12.2 - Herbs, Dried Sweet Basil Leaves [12.2.1] Repacker -
sauces, salads and spices, General
protein products seasonings, Manufacturing
and
condiments

Kind Of Business: Trade/Retail - Wholesaler

Sl.No. Product(s)
1 02 - Fats and oils, and fat emulsions
2 04 - Fruits and vegetables (including mushrooms and fungi, roots and tubers, fresh pulses and
legumes, and aloe vera), seaweeds, and nuts and seeds
3 05 - Confectionery
4 06 - Cereals and cereal products, derived from cereal grains, from roots and tubers, pulses, legumes
and pith or soft core of palm tree, excluding bakery wares of food category 7.0
5 07 - Bakery products
6 11 - Sweeteners, including honey
7 12 - Salts, spices, soups, sauces, salads and protein products
8 14 - Beverages, excluding dairy products
9 15 - Ready-to-eat savouries

Kind Of Business: Trade/Retail - Retailer

Sl.No. Product(s)
1 02 - Fats and oils, and fat emulsions
2 05 - Confectionery
3 06 - Cereals and cereal products, derived from cereal grains, from roots and tubers, pulses, legumes

Page 9 of 11
 Sl.No. Product(s)
and pith or soft core of palm tree, excluding bakery wares of food category 7.0
4 07 - Bakery products
5 04 - Fruits and vegetables (including mushrooms and fungi, roots and tubers, fresh pulses and
legumes, and aloe vera), seaweeds, and nuts and seeds
6 11 - Sweeteners, including honey
7 12 - Salts, spices, soups, sauces, salads and protein products
8 14 - Beverages, excluding dairy products
9 15 - Ready-to-eat savouries

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
& 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 *

Page 10 of 11
 S.No. Documents Submission Document
Type Uploaded/
FBO Remarks
9 Recall Plan * View Sample Document Mandatory view
10 Production unit photographs 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. 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

घोषणा || अनुज्ञिप्त की शतेर्ं || िनरीक्षण जांच सूची

Page 11 of 11