A/IRS/1-09
Ministry of Health Malaysia
APPLICATION FORM FOR THE APPROVAL OF INDEPENDENT REFRIGERATED STORE
IN THE EUROPEAN UNION (EU) SUPPLY CHAIN
1.0 Type of Application(1): New Re-apply
Others, please specify …………………………………………………………
2.0 Particulars of Applicant
2.1 Name of Applicant: ………………………………………………………………………………………………….………….
2.2 NRIC Number: ……………………………………………………………………………………………………………………
2.3 Name and Address of Company: ……………………………………………………………………………………………
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......
2.4 Tel. No.: …………………………. 2.5 Fax No.: ……………………………....2.6 H/P No. ……………………………..
2.7 E-mail address: …………………………………………………………………………………………………………………..
2.8 Company Registration Number (ROC): …………………………………………………………………………………..
(Please attach copy of the certificate)
2.9 Address / Location of Independent Refrigerated Store: ……………………………………………………………..
……………………………………………………………………………………………………………………………………………..
Postcode :………………………..District: …………………………………….....State :……………………………......
2.10 Correspondence Address (if different from para 2.3): .……………………………………………………………..
……………………………………………………………………………………………………………………………………………..
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(1) Tick () where appropriate
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3.0 Particulars of Workers
3.1 Have the workers been medically examined in accordance with the Guideline for Medical Examination for Food Handlers in Fishery Product Industries in Malaysia which is available at the website ?(1)
YesNo
If yes, please attach the names of the workers and the copies of their medical examination reports as in Appendix II of the guideline.
3.2Have the workers attended any training on basic hygiene?(1)
YesNo
If yes, please attach the names of the workers,name and date of training,name of trainer and training institution.
4.0 Requirement for Independent Refrigerated Store
4.1 Approval is subjectto the compliance with the EU requirementswhich includeRegulation (EC) No 852/2004, on the hygiene of foodstuffs which is availableat the website
4.2 Applicant shall submit relevant document i.e. Standard Operating Procedure of Independent Refrigerated Store which is to be based on Food Safety Assurance Programme such as HACCP, Good Manufacturing Practices or Good Hygiene Practices.
(1) Tick () where appropriate
5.0 Applicant Declaration
I ……………………………………………………………………………….
(Name of Applicant)
Declare that:
- the information supplied in this application is true ;
- Have fulfilled the EU requirements for fishery products.
………………………………....
(Signature of Applicant)
…………………………………………...... ……………………………………
(Name of Applicant) (Company Stamp)
………………………………..
(Date)
6.0 Please return completed application form to:
Director
Food Safety and Quality Division
Ministry of Health Malaysia
Level 3, Block E7, Complex E,
62590 Putrajaya
Tel. No :03-88833558
Fax. No :03-88893815
FOR OFFICIAL USE ONLY
7.0 Result of Inspection (to be completed by the inspector)
Complying
Independent refrigerated store is recommended to be approved
Non-complying
Remarks:......
......
Final inspection report attached
Signature:......
Name of Inspector:......
Date:...... Official Stamp
8.0 Approval Status (to be completed by Food Safety and Quality Division, Ministry of Health)
Approved
Not approved
Remarks:......
......
Signature:......
Name of Officer:......
Date:...... Official Stamp
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