_______________AREAFood Safety and Standards Rules –2011

(Rule 2.4.1.8)

1. DO Code Number :__ and Serial No: of the Sample.

II. Name of the sender his official designation : _______________Food Safety Officer

III. Date and place of collection :

IV. Nature of articles being sent for analysis : V. Nature and quantity of preservative,if any, added to the sample. :

Sign. of Food Business Operator Food Safety OfficerFSO Code No:__

_______________AREAFood Safety and Standards Rules –2011

(Rule 2.4.1.8)

1. DO Code Number : __ and Serial No: of the Sample.

II. Name of the sender his official designation : _______________Food Safety Officer

III. Date and place of collection :

IV. Nature of articles being sent for analysis : V. Nature and quantity of preservative,if any, added to the sample. :

Sign. of Food Business Operator Food Safety OfficerFSO Code No:__

CUMBUM MUNICIPALAREAFood Safety and Standards Rules –2011

(Rule 2.4.1.8)

1. DO Code Number : __ and Serial No: of the Sample.

II. Name of the sender his official designation : _______________Food Safety Officer

III. Date and place of collection :

IV. Nature of articles being sent for analysis : V. Nature and quantity of preservative,if any, added to the sample. :

Sign. of Food Business Operator Food Safety OfficerFSO Code No:__

_______________AREAFood Safety and Standards Rules –2011

(Rule 2.4.1.8)

1. DO Code Number : __ and Serial No: of the Sample.

II. Name of the sender his official designation : _______________Food Safety Officer

III. Date and place of collection :

IV. Nature of articles being sent for analysis : V. Nature and quantity of preservative,if any, added to the sample. :

Sign. of Food Business Operator Food Safety OfficerFSO Code No:__

ACKNOWLEDGEMENT OF DESIGNATED OFFICER

[See Rule 2.4.1 (10) (ii)]

I acknowledge the receipt of the remaining of two/three sealed parts of the food sample of

................................................................................................................................................. bearing DO.Code No:__ &

Sl.No................................................................. dt . .............................................. along with Form VI and Specimen

Impression of seal for each part of Sample from _______________ , Food Safety Officer,

_______________Area today on.........................................................

DESIGNATED OFFICER _____________ DISTRICT

ACKNOWLEDGEMENT OF DESIGNATED OFFICER

[See Rule 2.4.1 (10) (ii)]

I acknowledge the receipt of the remaining of two/three sealed parts of the food sample of

................................................................................................................................................. bearing DO.Code No:__ &

Sl.No............................................................. dt . .............................................. along with Form VI and Specimen

Impression of seal for each part of Sample from _______________ , Food Safety Officer,

_______________Area today on.........................................................

DESIGNATED OFFICER _____________ DISTRICT

FOOD SAFETY OFFICER DIARY

Name of the Food Safety Officer :_______________ DO Code No:__

1. Date of Sampling : Sl.No:

Day/Time :

2.License / Registration No :

Name of the Licensee/Registree :

3.Name of the Vendor : Age:

S/O

Address Shop:

Ph.no:

Residence:

Ph.no:

4. Nature of Sample :

Batch no: Best Before:

Expiry Date: MRP:

ISI/ Agmark /BIS Mark Details :

Stock in hand of Vendor :

Quantity sampled :

5.Cost of Stock :

Cost of Sample :

6.Type of preservative added/ : Details & Quality

7. If ,Vendor is a staff employed . ThenAddress of the Owner : Age:

S/O

Residence:

Ph.no:

a) Address of the Agent/Wholesaler :

b) Address of the Distributer :

c) Address of the Manufacture :

8.Witness Address 1) : Age

S/O

Residence :

Phone :

Address-2 : Age:

S/O

Residence :

Phone :

9. Is FBO willing for private lab Analysis : Yes /No

If yes Details of Govt. Approved Private Food Lab :

Food Safety OfficerFSO Code No:__

Government of Tamil NaduTamil Nadu Food Safety & Drug Administration Department(Food Wing)

FORM V AFORM OF NOTICE To THE FOOD BUSINESS OPERATOR

(Refer Rule 2.4.1. (3))To

--------------------------------------------------

-------------------------------------------------

-------------------------------------------------

Dear Sir/s/ Madam:

I have this day taken the samples of food from premises/shop/market of

situated at

as

specified below to have the same analysed by the Food Analyst for ______________________Area.

Details of food:

DO Code number: __ And Sl.No_

P a r a met e r to be tested: 1. As per the FSSAI Standards for the specific products2. Any additional test to be performed if any

Place:

Date:

Food Safety OfficerFSO Code No: __

_______________Area

Acknowledgement:

Sign. of Food Business Operator

Witness1:

Witness2:

_______________AREA FORM VIMEMORANDUM TO FOOD ANALYST

DO Code No: __Sl .No :

Date:

From : _______________ To: The Food Analyst,Food Safety Officer, Food Analysis Laboratory, FSO Code No: __ ____________________, _______________Area, _____________________, ____________ District. ____________________

MEMORANDUM

(Refer Rule 2.4.1(11))

1.The sample described below is sent herewith for analysis under clause ‘a’ of sub-section 1 of Section 38 and Section 47 (1)(c)(i) of Food Safety and Standards Act, 2006 .

i) Code Number & Sl.No.of DO : DO.CODE No:____ And Sl.No:

(ii) Date and place of collection :

(iii) Name/Nature of articles submitted for analysis

:

(iv) Name/Nature and quantity of preservative, if any, added to the sample.

:

2. A copy of this memo and specimen impression of the seal used to seal the packet of sample are being sent separately by post/courier/hand delivery (strike out whichever is not applicable)

ManufacturerWholesaler Food Safety OfficerRetailer FSO Code No: ___Hawker` _______________Area

INTIMATION LETTER TO THE DESIGNATED OFFICER [See Sec. 47 (1)(c)(i)]

To :The Designated Officer, DO.Code :______________ District. Sl.No:

I submit that I have taken Food Sample of ......................................................................................................... bearing DO Code No.___ and Serial No…………….................................... under The Food Safety & Standard Act -2006 from the below mentioned Person on ................................. I am sending one portion with- From VI and Specimen Impression Seal to The Food Analyst ,_________ on .................................... for analysis and the remaining two/three portions with Form VI & Specimen Impression Seal for each are handed over for safe custody . It is also

informed that the 4th part of the sample has been sent to

as requested by the Food Business Operator.

The details of the sample are as follows :-1 Name ..2 Father's Name ..3 Age ..4 Address ..

5 Whethera) Manufacturer ..a) Whole sealer ..b) Retailer ..c) Hawker ..

6 Date, Time & place of sampling ...

7 From a stock of ..8 Quantity lifed ..9 Cost of the sample ..10 Previous samples or conviction if ..

any11 Remarks ...

Food Safety Officer FSO Code No:__

_______________Area

_______________AREA

From : _______________ To: The Food Analyst,Food Safety Officer, Food Analysis Laboratory, FSO Code No: __ _____________________, _______________Area, _____________________,

__________ District.

DO Code No: __ Sl. No: Dated:

MEMO R AND U M OF S P E CIMEN IM PR ESSION OF SEAL U SED

(Refer Rule 2.4.1(11))

The Specimen Impression of the Seal used to seal the container is sent herewith separately for

verification.

FoodSafetyOfficerFSO Code No:__

_______________Area

Specimen Impression of the Seal used

_______________AREA

From : _______________ To: The Food Analyst,Food Safety Officer, Food Analysis Laboratory, FSO Code No: __ _____________________, _______________Area, _____________________,

__________ District.

DO Code No: __ Sl. No: Dated:

MEMO R AND U M OF S P E CIMEN IM PR ESSION OF SEAL U SED

(Refer Rule 2.4.1(11))

The Specimen Impression of the Seal used to seal the container is sent herewith separately for

verification.

FoodSafetyOfficerFSO Code No:__

_______________Area

Specimen Impression of the Seal used

'FORM D-1’ Annual Return

(For business other than Milk and Milk products) (See Regulation 2.1.13)

1. Name and address of Licensee:-

2. Address of the authorized premises for the manufacturing / Re-Packing/ Re- Labeling of food products:

3. License No. ..............................

4. Statement showing quantities of food products manufactured/handled/imported and exported in Tonnes

Name of the food product manufacture d/handled/i mported/exported.

Size of can / bottle/any otherpackage (likePP) or bulk package

Quantit y in MT

Sale price per Kg or per unit of packing

Value Quantity exported/i mported in Kg

1 2 3 4. 5 6

Name of the country or port of Export

Rate per Kg or per unit of packing C.I.F./F.O.B.

Value Remarks

7 8 9 10

Signature of the Licensee

FORM EForm of

Guarantee(Refer Regulation

2.1.14(2))I nvoice No.

From: Place: Date:

To:

Date of sale

Nature and quality of article/brand name, if any

Batch No or CodeNo

Quantity Price

I /We hereby certify that food/foods mentioned in this invoice is/are warranted to be of the nature and quality which it/these purports/purported to be.

Signature of the manufacturer/Distributor/Dealer

Name and address ofM manufacturer/Packer(in case of packed article)License No. (Wherever applicable)

FORM IFORM OF AFFIDAVIT

Seizure of books of account and other documents(Refer Rule 2.2.2)

I, son of/wife of/daughter of Mr. , aged about years and residing at

do hereby solemnly affirm and sincerely state as follows:

1. I am the sole proprietor/Partner/Director/employee of Private Ltd/Limited (here give

the name of the firm or Company) having its Office/carrying on business//Registered Office at _.

2. I say that on at about a.m./p/m., the Food Safety Officer, _(here give the

area of operation of the Food Safety Officer) inspected/searched the premises at where

I am/ Private Ltd./Limited is carrying on business. During the course of such inspection/search,

the Food Safety Officer has seized certain books of account and documents relating to the business.

3. I say that the books of accounts and other documents seized during the inspection/search are required for

carrying on business and hence it is necessary that they be returned to me immediately.

4. At my request, the Food Safety Officer has agreed to return the books of account and other documents so

seized during the inspection/search, subject to my providing him extracts or copies of such books of account

and other documents. The Food Safety Officer has given me the details of the extracts or the copies required

by him.

5. I say that I have caused the extracts/copies so required to be taken in the presence of the Food Safety

Officer/ (name) an officer working in the department of the Food Safety Officer.

6. I confirm and declare that the extracts/copies annexed to this Affidavit are the true, authentic and genuine

extracts/copies of books of account/other documents seized on and in confirmation thereof, I have

initialed each page of such extracts/copies.

7. I am aware that based on the solemn declarations given in this Affidavit, the Food Safety Officer has agreed

to return the books of accounts and other documents seized as aforesaid on _.

8. I hereby undertake to produce the books and accounts and other documents or any part thereof at any time

as may be required by the Designated Officer or by the Food Safety Officer or before any inquiry proceedings

or before any adjudication proceedings that may be initiated by the Food Safety Officer against me or against

_Private Ltd./Limited or both..

(SIGNATURE OF THE DEPONENT)

Solemnly affirmed and

signed before me this of

Notary Public.

GOVERNMENT OF TAMILNADUTAMILNADU FOOD SAFETY & DRUG ADMINISTRATION DEPARTMENT ( FOOD WING)

FORM II SEIZURE MEMO [Refer Rule 2.3.1]

In exercise of the power delegated to me under section38 of the FSS Act, I hereby seize/detain the under

mentioned food products/documents which contravene the provision of section—————————————

————— of this Act at the premises of M/S———————————————————————————

Sl.No. Name of the products Batch No. No of units Qty in kgs .

The detention/seizure has been made and the inventory has been prepared in presence of the following witnesses.

Name and address of the witness signature.

1.

2.

The products detained/seized have been duly sealed and are left in the custody of Shri.——————————

———————————————————————————————————with the instruction not to

tamper with the seals and not to dispose of the products till further order.

Signature of Manufacturer/dealer FOOD SAFETY OFFICER

Name: ______________________

_______________AREA

Date:

GOVERNMENT OF TAMILNADUTAMILNADU FOOD SAFETY & DRUG ADMINISTRATION DEPARTMENT ( FOOD WING)

FORM IIIFORM OF ORDER OF SEIZURE

[Refer Rule 2.3.2.(1)]To

(Name and address of the Food Business Operator)

…………………………………...............................

…………………………………...............................

…………………………………...............................

Whereas below mentioned articles of food….intended for sale which is in your possession appears to me to be

adulterated/misbranded under in violation of section————————————————of FSS Act:

Sl.No. Name of the products Batch No. No of units Qty in kgs .

Now therefore under clause (c) of sub-section (1) of section 38 of the Food Safety and Standards Act, 2006 (34

of 2006),I hereby direct you to keep in your safe custody the said sealed stock subject to such orders as may

be issued subsequently in relation thereto.

Date: FOOD SAFETY OFFICER

Name: _______________________

______________________AREA

GOVERNMENT OF TAMILNADUTAMILNADU FOOD SAFETY & DRUG ADMINISTRATION DEPARTMENT ( FOOD WING)

FORM IV[Refer Rule 2.3.2.(2)]

FORM OF SURETY BOND

Know all men by these present that we (i) …………….……………..son of ………………….…………resident of…………………………………………………………………………………..and (ii) ………………………. son of……………………………...resident of ………………………………………………………………………. proprietors/partners/employees of Messrs ………………………..…….hereinafter called the Food Business Operator (s) and (iii)…………………..…………..son of ………………..………..resident of……………………………………………………………………………..…….and (iv) ………….………son of……………….resident of………………………………………………………………………….……….hereinafter called the surety/sureties are held and firmly borne up to the President of India/Governor of TamilNadu hereinafter called the government in the sum of ………………………..…………..rupees to be paid to the government, forwhich payment will and truly be made. We firmly bind ourselves jointly and severally by these presents.Signed this …………day of …..……………….whereas Shri _______________, Food Safety Officer has seized……………………………………………………………………………………………………………………. (here, insert the description of materials together with number/quantity and total price hereinafter referred to as the said article) from …………………………………………………………………………………………………..…. (specify the place); Whereas on the request of the Food Business Operator(s) the government has agreed to keep the said article in the safe custody of the Food Business Operator(s) executing a bond in the terms hereinafter contained and supported by surety/two sureties which the Food Business Operator(s) has/have agreed to do. Now the condition of the above written obligation is such that if in the event of the Food Business Operator(s) failure to produce intact the said article before such court or Authority and on such dates(s) as may be specified by the said Food Safety Officer from time to time the Food Business Operator(s) and /or the surety/sureties forthwith pay to the government on demand and without a demur sum of …….………rupees and there after the said bond will be void and of no effect. Otherwise the same shall be and remain in full force and virtue.These presents further witness as follows:(i) The liability of the surety/sureties hereunder shall not be impaired or discharged by reason of time being granted by or any forbearance, act or omission of the government whether with or without the knowledge or consent ofthe sureties or either of them in respect of or in relation to all or any of the obligations or conditions to be performed or discharged by the Food Business Operator(s). Nor shall it be necessary for the government to suethe Food Business Operator(s) before suing the sureties or either of them for the amount due, hereunder.(ii) This Bond is given under the Food Safety and Standards Act,2006 for the performance of an Act in which the public are interested.(iii) The government shall bear the stamp duty payable on these presents.In witness whereof these presents have been signed by the Food Business Operator(s) and the surety/sureties the day hereinabove mentioned and by Shri _______________,Food Safety Officer, ___________________Area on behalf of the President of India on the date appearing below against his signature.

Witnesses:1.……………………. (Signature)

(Name and address)…………………..

2……………………. (Signature) (Name and address)…………………..

Signature………………… (Food Business Operator)………

Signature………………… (Food Business Operator)………

Signature………………….. (Surety)………

Signature………………….. (Surety)………

For and on behalf of thePresident of India / Governor of state of TamilNadu

.Food Safety Officer,

_______________Area.

GOVERNMENT OF TAMILNADUTAMILNADU FOOD SAFETY & DRUG ADMINISTRATION DEPARTMENT ( FOOD WING)

FORM NO. IX(Form of Nomination – Refer rule 2.5.1)

NOMINATION OF PERSONS BY A COMPANY

Being the proprietor or a signatory authorized by the board of directors of the company in terms of Rule

2.5.1 (2), I do hereby gives notice that the following persons(s) is/are nominated as the person(s) in charge of

establishment, branch or the unit mentioned against the name of the person(s) and shall be responsible and

liable for food safety or any contravention of the Act and rules/regulations or directions issued there under in

respect of the concerned establishment/branch/unit. The person(s) shall take all such steps as may be

necessary to prevent the commission by the Company of any offence under and comply with the provisions of

Food Safety and Standards Act, 2006 and the Rules and Regulations made there under.

Branch wise/office wise nomination .

Establishment/branch/unit name Name and Sign of Person i/c

1. 1.

2. 2.

3. 3.

A certified copy of the resolution of the board regarding the authorized signatory, dated is enclosed.

Place:

Date: For Ltd./Private Ltd.

1. Authorized signatory of the company

Place:

Date:

தமிழ்நாடு அரசு

உணவு பாதுகாப்பு மற்றும் மருந்து நிர்வாகத்துறை� (உணவு பிரிவு) படிவம் - V A

உணவு பபாருள் விற்பறை#யாளருக்கு வழங்கப்படும் அ�ிவிப்பு [ (Refer Rule 2.4.1. (3))

பெ�றுநர் : திரு/திருமதி:

த/பெ�: முகவரி :

..................................................................................... �குதிக்கான உணவு �ரிச�ாதகரால் �ரிச�ாதனைன பெ�ய்யப்�டுவதற்காக உங்களிடமிருந்து கீழ் குறிப்�ிடப்�ட்ட உணவு பெ�ாருளின் மாதிரினைய உணவு�ாதுகாப்பு அலுவலரான நான் இப்பெ�ாழுது எடுக்க இருக்கிசறன் என்று அறியவும்.கனைட /நிறுவனத்தின் முகவரி; :

உணவு பெ�ாருளின் வி�ரம்; :

DO.Code No:__ மற்றும் Sl.No:

�ரிச�ாதனைனகளின் வி�ரம் ; : 1. உணவு �ாதுகாப்பு மற்றும் தரநிர்ணயச்�ட்டத்தின்�டி சமற்�டி உணவு பெ�ாருளுக்குநிர்ணயிக்கப்�ட்ட தரத்தின் �டி உள்ளதா எனவும்;.

2. கூடுதலாக சதனைவப்�டும் �ிற �ரிச�ாதனைனகளும் பெ�ய்யப்�டும்.

உணவு �ாதுகாப்பு அலுவலர் FSO Code No: __ ...........................................................

�குதி

சமற்�டி அறிவிப்பு �ிரதினைய பெ�ற்றுக்பெகாண்சடன்.

உணவு பெ�ாருள் விற்�னைனயாளர் னைகபெயாப்�ம்;

�ாட்�ிகள் ::1.

2.

பராக்க ரசீது

அனுப்பு#ர் : திரு._______________________ DO Code No: ___________________________ Sl. No:

___________________________.

இன்று (தேததி)........................................................... நான் விற்பறை#க்கு றைவத்திருந்த ( உணவுப்பபாருள்) ...................................................................... .............................................லிருந்து திரு _____________________ உணவுபாதுகாப்புஅலுவலர் , ................................................ பகுதிஅவர்களுக்கு உணவுபகுப்பாய்வரால் பகுப்பாய்வு ப6ய்யும் பபாருட்டு விற்� (அளவு) ............................................................ க்கு தங்களிடமிருந்து நான் ரூபாய்............................... (எழுத்தால்) ....................................................................... ..........................................................................................மட்டும் பபற்றுக்பகாண்தேடன் அதற்கு இதுதேவ ரசீது.

இப்படிக்கு

6ாட்6ிகள்:

1.

2.

பராக்க ரசீது

அனுப்பு#ர் : திரு._______________________ DO Code No: ___________________________ Sl. No:

___________________________.

இன்று (தேததி)........................................................... நான் விற்பறை#க்கு றைவத்திருந்த ( உணவுப்பபாருள்) ...................................................................... .............................................லிருந்து திரு _____________________ உணவுபாதுகாப்புஅலுவலர் , ................................................ பகுதிஅவர்களுக்கு உணவுபகுப்பாய்வரால் பகுப்பாய்வு ப6ய்யும் பபாருட்டு விற்� (அளவு) ............................................................ க்கு தங்களிடமிருந்து நான் ரூபாய்............................... (எழுத்தால்) ....................................................................... ..........................................................................................மட்டும் பபற்றுக்பகாண்தேடன் அதற்கு இதுதேவ ரசீது.

இப்படிக்கு

6ாட்6ிகள்:

1.

2.

அனுப்புனர் : திரு.

.........................................................

.......................................................பெ�றுநர் : உணவு �ாதுகாப்பு அலுவலர் அவர்கள்>

........................................................................... �குதி> உணவு �ாதுகாப்பு மற்றும் மருந்து நிர்வாகத்துனைற>

.................................. மாவட்டம்.ஐயா>

.......................................................................................................................................................................என்ற முகவரியில் அனைமந்துள்ள எனது உணவு விற்�னைன கனைடயில்> jq;fshy; ………………………… md;W உணவு �ரிச�ாதனைனக்காக எடுக்கப்�ட்ட

............................................................................... உணவு மாதிரியிலிருந்து உணவு வணிகர்களுக்கான

(4k;gFjp) மாதிரினைய அர�ால் அனுமதிக்கப்�ட்ட தனியார் �ரிச�ாதனைன கூடத்திற்கு

�ரிச�ாதனைனக்கு அனுப்�ி னைவக்குமாறு சகட்டுக்பெகாள்கிசறன். அதற்கான �ரிச�ாதனைன கட்டணம்

ரூ�ாய்..................... க்கான வங்கி வனைரசவானைலனைய இத்துடன் இனைணத்துள்சளன்.

வங்கி வனைரசவானைல எண் : சததி:

வங்கியின் பெ�யர்:

இப்�டிக்கு

�ாட்�ிகள்:

அனுப்புனர் : திரு.

.........................................................

.......................................................பெ�றுநர் : உணவு �ாதுகாப்பு அலுவலர் அவர்கள்>

......................................................................... �குதி> உணவு �ாதுகாப்பு மற்றும் மருந்து நிர்வாகத்துனைற>

............................................. மாவட்டம்.

ஐயா>

.......................................................................................................................................................................என்ற முகவரியில் அனைமந்துள்ள எனது உணவு விற்�னைன கனைடயில்> jq;fshy; ………………………… md;W உணவு �ரிச�ாதனைனக்காக எடுக்கப்�ட்ட

............................................................................... உணவு மாதிரியிலிருந்து உணவு

வணிகர்களுக்கான(4k;gFjp;) மாதிரினைய அர�ால் அனுமதிக்கப்�ட்ட தனியார் �ரிச�ாதனைன

கூடத்திற்கு �ரிச�ாதனைனக்காக அனுப்� vdf;F விருப்�மில்னைல என்�தனைன சுய நினைனவுடன்

பெதரிவித்துபெகாள்கிசறன்.

இப்�டிக்கு

�ாட்�ிகள் :

GLASS WITH CARE

TO:THE FOOD ANALYST,FOOD ANALYSIS LABOROTARY,___________________________,_______________________________,_______________________________

FROM: _______________, FOOD SAFETY OFFICER, _________________________ Area, ____________ DISTRICT.

GLASS WITH CARE

TO:THE FOOD ANALYST,FOOD ANALYSIS LABOROTARY,___________________________,_______________________________,_______________________________

FROM: _______________, FOOD SAFETY OFFICER, _________________________ Area, ____________ DISTRICT.