Form 'B'

[See Regulation 2.1.2, Regulation 2.1.3 and Regulation 2.1.7]

Application for License / Renewal of license under Food Safety and Standards Act, 2006
Application Reference No.

: 20140904123115363

Name of
: Anubhav Infotech
Company/Organization/Applicant

Application
: New License
Type
Application
: 08/09/2014
Date

LG-15, Rama Arcade,

Gulmohar,
Kind of
:
Trilanga, Bhopal,
Business
Bhopal

Address

Caterer,Club/Canteen,Distributer,Food
vending Establishment,Retailer

Registered Office Detail(s)

Address

LG-15, Rama Arcade, Gulmohar,

Trilanga

State

Madhya Pradesh

District

Bhopal

Pin Code

462016

Address of Premises for which license is applied

Address

LG-15, Rama Arcade, Gulmohar,

Trilanga

State

Madhya Pradesh

District

Bhopal

Pin Code

462016

District

Bhopal

Pin Code

462016

Correspondence Address
Address

E-3, Senior MIG-15, Arera Colony,

Opposite Nupurkunj

State

Madhya Pradesh

Contact Information
Telephone
07554096000
No.

Fax
Email-ID

Mobile No. 9826010002

a.in.bpl@gmail.com

Person in charge of operations

Name

Ashesh Tiwari

Pin Code

Qualification BE. MBA

Address

E-3, Senior MIG-15, Arera Colony,

Opposite Nupurkunj

State

Madhya Pradesh

District

Bhopal

462016

Contact
No.
Mobile No. 9826010002
Email-ID
Photo ID

a.in.bpl@gmail.com
Pan Card,ABUPT8448G

Person responsible for complying with conditions of License

Name

Mayank Pandey

Pin Code

Qualification B Com MBA

462016

Contact
No.

Address

E-3, Senior MIG-15, Arera Colony,

Opposite Nupurkunj

State

Madhya Pradesh

Mobile No. 7354880115

District

Bhopal

Email-ID
Photo ID

A.IN.BPL@GMAIL.COM
Voter ID,NMU1576719

Kind of Business : Food Business Operator

Retailer
Sl.No
1
2

Food Product Category

01 - Dairy products and analogues, excluding products of food category 02.0
05 - Confectionery

3
4
5

07 - Bakery products
14 - Beverages, excluding dairy products
10 - Eggs and egg products
04 - Fruits and vegetables (including mushrooms and fungi, roots and tubers, fresh pulses and legumes, and
aloe vera), seaweeds, and nuts and seeds
15 - Ready-to-eat savouries
17 - Products not covered into category 1-16 (Ice Creams)

6
7
8

Distributer
Sl.No
1
2

Food Product Category

12 - Salts, spices, soups, sauces, salads and protein products
14 - Beverages, excluding dairy products

Caterer
Sl.No

Food Product Category

1
2

16 - Prepared Foods
12 - Salts, spices, soups, sauces, salads and protein products

Dhaba, Home based Canteens/ Dabba Wallas, Permanent/ Temporary stall Holder, Food stalls/
Arrangements in Religious gatherings, fairs , Fish/Meat/Poultry shop/Seller or any other food vending
establishment
Sl.No
1

Food Product Category

12 - Salts, spices, soups, sauces, salads and protein products

14 - Beverages, excluding dairy products

Club/Canteen
Sl.No

Food Product Category

14 - Beverages, excluding dairy products

Already Holding License

Other License

No
No

Document(s) Details
SNo.

1
2

3
4
5
6
7

8
9
10
11
12

Document(s)
Form-B Duty completed and signed (In Duplicate) by the Proprietor/Partner or the
Authorized Signatory
Blueprint/layout plan of the processing unit showing the dimensions in metres/square
metres and operation-wise area allocation (mandatory for manufacturing and
processing units only)
List of Directors/Partners/Proprietor/Executive Members of Society/Trust with full
address and contact details (mandatory for companies only)
Name and List of Equipments and Machinery along with the number, installed capacity
and horse power used (mandatory for manufacturing and processing units only)
Photo I.D and address proof issued by Government authority of
Proprietor/Partner/Director(s)/Authorised Signatory. (optional)
List of food category desired to be manufactured. (In case of manufacturers)
Authority letter with name and address of responsible person nominated by the
manufacturer along with alternative responsible person indicating the powers vested
with them viz assisting the officers in inspections, collection of samples, packing &
dispatch. (for manufacturers / processors)
Analysis report (Chemical & Bacteriological) of water to be used as ingredient in food
from a recognized/ public health laboratory to confirm the portability (mandatory only
for manufacturing and processing units only)
Proof of possession of premises. (Sale deed/ Rent agreement/ Electricity bill, etc.)
(optional)
Partnership Deed/Affidavit of Proprietorship/Memorandum & Articles of Association
towards the constitution of the firm. (optional)
Copy of certificate obtained under Coop Act - 1861/Multi State Coop Act - 2002 in case
of Cooperatives. (wherever applicable)
NOC from manufacturer (mandatory for relabellers and repackers only)

Document
Submission Uploaded /
Type
FBO
Remarks
Not Applicable

Not Applicable

Physically

ASHESH TIWARI
E3, Senior MIG
15, Arera
Colony, Bhopal

Not Applicable
Electronically

View

Not Applicable

Not Applicable

Not Applicable

Electronically
Not Applicable
Not Applicable
Not Applicable

View

13
14
15
16
17
18
19
20

Physically
Not Applicable
Food Safety Management System plan or certificate (if any)
Source of milk or procurement plan for milk including location of milk collection centres
Not Applicable
etc. in case of Milk and Milk Products processing units.(wherever applicable)

Source of raw material for meat and meat processing plants. (wherever applicable)
Pesticide residues report of water in case of units manufacturing packaged drinking
water, packaged Mineral water and/or carbonated water from a recognised/ public
health laboratory
Recall plan wherever applicable, with details on whom the product is distributed.
(optional)
NOCs from Municipality or local body. (optional)
Form IX: Nomination of Persons by a Company Click here to Download
Board Resolution with respect of Nominee

Not Applicable
Not Applicable

Not Applicable
Not Applicable
Not Applicable
Not Applicable

Payment Details
Amount

Rs. 6000

Payment Mode

Online Transaction No

14090719593675333503 Transaction Date

MP Online
06/09/2014

Place :
Date :

______________________________________
(Signature of the applicant/authorized signatory)