No.

Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 03

Quality & Food SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 17 Juli 2019
Safety Department (Raw Material) Halaman : 1 dari 4

A. MATERIAL DATA
Supplied Material :
Material Code :

B. PRODUSEN DATA

Name of Manufacture :
Country :
Address :
Telephone :
Fax :
Email :
Website :
Name of Owned Certificate : ISO 9001:2008 / ISO 22000:2005 / FSSC 22000 /
ISO TS 22002:2009 / BRC / NOT AVAILABLE

C. SUPPLIER DATA
Name of Supplier : CV. Harum Mekar
Produsendan Supplier tepungTapioka&Onggok
KawasanIndustriKranji Ds. NgemplakkidulKec. Margoyoso
Kab. PatiJawa Tengah
Address :
Telephone : 081310236103
Contact Name : Danang Hendri Wibowo
Job Title : Marketing

[email protected] , [email protected]
Email :
Fax :

D. DATA HAS BEEN GIVEN BY :

Name :
Position :
Date :
Email :
Fax :

E. CRISIS MANAGEMENT CONTACT

Name : Danang Hendri Wibowo
Telephone : 081310236103
Fax : :

1. Both the suppliers and PT. Kobe Boga Utama commit to keep the existence and the contents of this document strictly confidential, as well as any information exchanged
between them under or in connection with the Food Safety Visa procedure.
2. The supplier acknowledges that it must at all times keep food safety risks under control and assumes all responsibilities in this respect.
3. The supplier further agrees that PT Kobe Boga Utama may at any time carry out a due diligence exercise in respect of food safety matters. For that purpose, the supplier
shall make available any relevant document and information which is reasonably requested by PT Kobe Boga Utama.
4. This document is limited for collecting information from supplier PT Kobe Boga Utama, in context of risk assessment of Food Safety.
5. Supplier be necessary to control and protect food safety consequences with full-responsibility every time.
6. Supplier also agree if audit supplier / manufacturer (due diligence) is happened anytime, in terms of food safety.
7. Supplier is proactively responsible for informing PT. Kobe Boga Utama before doing any changes, which may affect food safety of the products (such as, source of raw
material, composition, production sites / production lines, etc.)
8. Supplier is able and guarantee the continuity of supplying which is suitable the rules, specification, and standard that already determined. The capability and
guarantee based on an agreement

NOTES :
Supplier has to attach
1. Copy of owned certificate of quality system (If any)
2. Copy of laboratory result or evidence of every test in this questionnaire (if applicable)
3. Copy of MSDS (if applicable)
4. Copy of Technical Data Sheet/RM Specification
5. Copy of Process Flow Diagram
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 03

Quality & Food SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 17 Juli 2019
Safety Department (Raw Material) Halaman : 1 dari 4

E. CHARACTERISTICS OF SUPPLIED PRODUCT YES NO NA

1. Product that has been supplied is a food grade v

2. Equipment that has been used for production process is a food grade v
3. Composition of supplied product :

Main Composition
Made From
Name Function Total Percentage
Area Country
Cassava starch Pati Indonesia 100%

Additive Substance

Name Function Total Food Grade (Yes/No)

4. Specification of Product:
Chemical - Physical - Organoleptic Information
Release
Parameter Standard Unit Value Monitoring Parameter
Parameter
Starch Content min 82 %
Moisture Max 16 %
Ash Content 0.5 %
pH solution Max 4 %

Microbiological Information
Release
Parameter Standard Unit Value Monitoring Parameter
Parameter

YES NO NA
5. Has supplied product been certificated halal ? v
If applicable, Please state from which institution certificate has been established :
Please attach halal certificate in attachment

6. Shelf life of raw material :

Condition of storage before it is opened :
Condtion of storage and handling after it is opened :
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 03

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 17 Juli 2019
Department (Raw Material) Halaman : 1 dari 4

F. ALLERGEN DECLARATION

Source of Allergen (fill with Yes or No in column)

Item Direct Possibility of Cross
Carry Over
Addition Contamination
Cereal with gluten and cereal - based products
Shellfish and shellfish - based products
Eggs and eggs - based products
Fish and fish - based products
Peanut and peanut - based products
Soy and soya - based products
Milk and milk - based products
Nuts and nuts - based products
Ex. Tree nuts, almond, pistachio, etc.
Celery and celery - based products
Mustard and mustard - based prodcts
Sesame seeds and sesame seeds - based products
Sulfur and sulphite dioyde (Anhydride) and products
manufactured with anhydride (and sulphites)
Lupin (Lupinus) and lupin - based products
Mollusc and mollusc - based products
Crustaceans
Glutamate
Enzyme

If product consists any of allergen above, please state : mg/kg

YES NO NA
Is there any procedure due to allergent management ? v

G. QUALITY & FOOD SAFETY MANAGEMENT SYSTEM

YES NO NA
1. Do you maintain a quality manual ? v
2. Does a procedure non conforming management for raw matterial and packaging matterial ? v
3. Do you have a policy to manage GMOs (Genetically Modified Organisms)? v
4. Do you have traceability system for product in operation ? v
5. Is there a glass material policy in your plant, including brittle material? v
6. Is the plant divided into different hygiene zones ? v
7. Do you have documentend cleaning programs on sites? v
8. Do you have CIP (Cleaning In Place) systems? v
9. Do you have pest control plan documentation (insect, rats, birds…) ? v
10. Does a guide and documented procedure for personnel hygiene exist? v
11. Does a crisis management procedure exist and relevant persons trained ? v
12. Does a recall procedure exist ?
13. Does a guide and documented procedure for Food Defense and Food Fraud ? v
14. Does a GMP guide and documented procedures exist ? v
15 Is there an HACCP plan implemented for all process ? v
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 03

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 17 Juli 2019
Department (Raw Material) Halaman : 1 dari 4

H. DECLARATION OF GENETICALLY MODIFIED ORGANISMS

Is there any material comes from plant(s) below:

Material Yes No
Corn
Soya
Grape Seed Oil
Cotton
Radish
Raw Rice
Potato
Papaya
Tomato
Wheat
Linseed
Eggplant

If yes, please attach free of GMO guarantee letter

G. CHEMICAL CONTAMINATION
YES NO NA
Is there any heavy metal and contaminated metal examination on supplied product?
If applicable, please specify the table below :
Heavy
Result Year
metal/chemical
Pb < 0.01 mg/kg 2015
Hg < 0.001 mg/kg 2015
As < 0.002 mg/kg 2015
Sn < 1.2 mg/kg 2015
Cd < 0.003 mg/kg 2015
Pesticide
Aflatoxin

H. PACKAGING MATERIAL
1. What type of material that has been used for packaging supplied product?
Primary Packaging : Plastic PE
Secondary PackagingPlastic Sack
YES NO NA
2. Has packaging material been certificated of Food Grade? v
3. Had migration test been done ? v
If yes, please attach laboratory result of migration test result

APPROVAL
Supplier Name : CV. Harum Mekar QFS : PT Kobe Boga Utama
Name : Sunar Name : Cahyo Noviarso
Title : Production Head Title :
Date : 6-Jul-20 Date :
Signature and Stamps
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 02

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 21 Maret 2019
Department (Raw Material) Halaman : 1 dari 4

A. MATERIAL DATA
Supplied Material : Isi: Nama produk yang disuplai ke Kobe

Material Code : Diisi jika Produk mempunyai kode material,

jika tidak ada kode material isi (-)

B. PRODUSEN DATA

Name of Manufacture : Isi: nama manufaktur

Country : Isi: negara manufaktur

Address : Isi: alamat manufaktur

Telephone : Isi: no telp manufaktur

Fax : Isi: no fax manufaktur

Email : Isi: email manufaktur

Website : Isi: website manufaktur

Coret yang tidak sesuai dengan aktual
Name of Owned Certificate : ISO 9001:2008 / ISO 22000:2005 / FSSC 22000 / manufaktur
ISO TS 22002:2009 / BRC / NOT AVAILABLE

C. SUPPLIER DATA
Name of Supplier : Isi: nama supplier

Address : Isi: alamat supplier

Telephone : Isi: telp supplier

Fax : Isi: fax supplier

Isi: contact person yang berhubungan dengan
Contact Name : Kobe

Isi: title person supplier yang berhubungan

dengan Kobe
Job Title :

Isi: alamat email person supplier yang

berhubungan dengan Kobe
Email :

Isian ini dimaksudkan karena supplier dalam mengisi isi form

D. DATA HAS BEEN GIVEN BY : 'supplier food safety visa' ini berdasarkan informasi dari manufaktur

Isi: nama personel manufaktur yang

memberikan data selama pengisian
Name :

Isi: posisi personel manufaktur yang

memberikan data selama pengisian
Position :

Isi: tanggal kapan data diberikan personel

yang memberikan data selama pengisian
Date :
Isi: alamat email personel yang memberikan
Email : data selama pengisian
Isi: no fax personel yang memberikan data
Fax : selama pengisian

E. CRISIS MANAGEMENT CONTACT

:
Isi: nama contact person supplier yg 24jam
bisa dihubungi jika ada kondisi krisis
Name

Isi: no telp person supplier yg 24jam bisa

dihubungi jika ada kondisi krisis
Telephone :
Isi: no fax supplier yg 24jam bisa dihubungi
Fax : : jika ada kondisi krisis

1. Both the suppliers and PT. Kobe Boga Utama commit to keep the existence and the contents of this document strictly confidential, as well as any information exchanged between them
under or in connection with the Food Safety Visa procedure.
2. The supplier acknowledges that it must at all times keep food safety risks under control and assumes all responsibilities in this respect.
3. The supplier further agrees that PT Kobe Boga Utama may at any time carry out a due diligence exercise in respect of food safety matters. For that purpose, the supplier shall make
available any relevant document and information which is reasonably requested by PT Kobe Boga Utama.
4. This document is limited for collecting information from supplier PT Kobe Boga Utama, in context of risk assessment of Food Safety.
5. Supplier be necessary to control and protect food safety consequences with full-responsibility every time.
6. Supplier also agree if audit supplier / manufacturer (due diligence) is happened anytime, in terms of food safety.
7. Supplier is proactively responsible for informing PT. Kobe Boga Utama before doing any changes, which may affect food safety of the products (such as, source of raw material,
composition, production sites / production lines, etc.)
8. Supplier is able and guarantee the continuity of supplying which is suitable the rules, specification, and standard that already determined. The capability and guarantee based
on an agreement

NOTES :
Supplier has to attach
1. Copy of owned certificate of quality system (If any) Lampirkan copy sertifikat quality system manufaktur
2. Copy of laboratory result or evidence of every test in this questionnaire (if applicable) Lampirkan copy hasil analisa lab jika dilakukan analisa
laboratorium
3. Copy of MSDS (if applicable) Lampirkan copy MSDS produk
4. Copy of Technical Data Sheet/RM Specification
Lampirkan Copy Spesifikasi/ Techical Data Sheet produk
5. Copy of Process Flow Diagram Lampirkan Copy diagram alir proses
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 02

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 21 Maret 2019
Department (Raw Material) Halaman : 2 dari 4

F. CHARACTERISTICS OF SUPPLIED PRODUCT YES NO NA

Isi: Yes jika produk yang disuplai ke Kobe bersifat food

1. Product that has been supplied is a food grade grade, isi NO jika produk yang disuplai ke Kobe tidak
bersifat food grade, isi NA jika pernyataan tsb tidak
applicable thd produk yg disuplai ke Kobe

Isi: Yes jika peralatan selama proses produksi produk yang

2. Equipment that has been used for production process is a food grade disuplai ke Kobe bersifat food grade, isi NO jika peralatan
selama proses produksi produk yg disuplai ke Kobe tidak
bersifat food grade, isi NA jika pernyataan tsb tidak
applicable thd produk yg disuplai ke Kobe
3. Composition of supplied product :

Main Composition
Made From
Name Function Area Country Total Percentage

Isi: komposisi utama produk yang disuplai ke Kobe

Additive Substance
Food Grade
Name Function Total
(Yes/No)

Isi: zat aditif pada produk yang disuplai ke Kobe jika ada
penggunakan zat aditif

4. Specification of Product:

Chemical/ Physical/ Organoleptic Information

Release Monitoring
Parameter Standard Unit Value
Parameter Parameter

Isi: untuk semua parameter: kimia, fisik, dan organoleptik

yang merupakan karakteristik produk yang disuplai ke
Kobe

Isi : standar/limit dari masing-masing parameter

Isi : satuan masing-masing standar/ limit

Isi : a jika parameter pengecekan merupakan parameter

release

Isi : a jika parameter pengecekan merupakan parameter

monitoring

Microbiological Information
Release Monitoring
Parameter Standard Unit Value
Parameter Parameter

Isi: untuk semua parameter: mikrobiologi yang merupakan

karakteristik produk yang disuplai ke Kobe

Isi : standar/limit dari masing-masing parameter

Isi : isi satuan masing-masing standar/ limit

Isi : a jika parameter pengecekan merupakan parameter

release
Isi : a jika parameter pengecekan merupakan parameter
monitoring

YES NO NA

Isi : Yes jika produk yang disuplai ke Kobe tersertifikasi

5. Has supplied product been certificated halal ? halal, No jika produk yang disuplai ke Kobe tidak
tersertifikasi halal, isi NA jika pernyataan tsb tidak
applicable thd produk yg disuplai ke Kobe
Isi : jika produk tersertifikasi halal, isi badan yang
If applicable, Please state from which institution certificate has been established : mensertifikasi halal produk tsb
Please attach halal certificate in attachment Lampirkan copy setifikat halalnya

6. Shelf life of raw material : Isi : umur simpan produk

Condition of storage before it is opened : Isi : rekomendasi penyimpanan produk jika produk masih
tertutup (belum dibuka)

Condtion of storage and handling after it is opened : Isi : rekomendasi penyimpanan produk jika produk sudah
dibuka
 No. Kode Dok :
KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 02

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 21 Maret 2019
Department (Raw Material) Halaman : 3 dari 4

F. ALLERGEN DECLARATION

Source of Allergen (fill with Yes or No in column)

Item Direct Possibility of Cross
Carry Over
Addition Contamination
Cereal with gluten and cereal - based products
Shellfish and shellfish - based products
Eggs and eggs - based products

Fish and fish - based products Isi : Yes jika pada produk ditambahkan raw material yang
merupakan alergen tsb, isi No jika pada produk tidak
ditambahkan raw material yang merupakan alergen tsb
Peanut and peanut - based products
Soy and soya - based products
Isi : Yes jika pada produk terdapat alergen yang terbawa
Milk and milk - based products oleh raw material dari produk tsb, isi No jika pada produk
tidak ada alergen yang terbawa oleh raw material dari
produk tsb
Nuts and nuts - based products
Ex. Tree nuts, almond, pistachio, etc.
Celery and celery - based products
Mustard and mustard - based prodcts
Sesame seeds and sesame seeds - based products

Sulfur and sulphite dioyde (Anhydride) and products Isi : Yes jika pada produk ada kemungkinan terdapat
manufactured with anhydride (and sulphites) alergen karena adanya kontaminasi silang, isi No jika pada
produk tidak ada kemungkinan terdapat alergen yang
disebabkan karena adanya kontaminasi silang
Lupin (Lupinus) and lupin - based products
Mollusc and mollusc - based products
Crustaceans
Glutamate
Enzyme

If product consists any of allergen above, please state : mg/kg Isi jumlah alergen yang terkandung jika ada, jika tidak ada
isi (-)
YES NO NA

Isi : Yes jika di manufaktur ada prosedur penanganan

Is there any procedure due to allergent management ? alergen, isi No jika di manufaktur tidak ada prosedur
penanganan alergen, isi NA jika NA jika pernyataan tsb
tidak applicable di produk/ manufaktur

G. QUALITY & FOOD SAFETY MANAGEMENT SYSTEM

YES NO NA

1. Do you maintain a quality manual ? Isi Yes jika manufaktur menerapkan 'quality manual', isi No
jika manufaktur tidak menerapkan 'quality manual', isi NA
jika pernyataan tsb tidak applicable di manufaktur tsb

2. Does a procedure non conforming management for raw matterial and packaging matterial ? Isi Yes jika manufaktur menjalankan prosedur penanganan
ketidaksesuaian bahan baku dan bahan kemas, isi No jika
manufaktur tidak menjalankan prosedur penanganan
ketidaksesuaian bahan baku dan bahan kemas, isi NA jika
pernyataan tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai kebijakan penanganan

3. Do you have a policy to manage GMOs (Genetically Modified Organisms)? GMO, isi No jika manufaktur tidak mempunyai kebijakan
penanganan GMO, isi NA jika pernyataan tsb tidak
applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai sistem mampu telusur

4. Do you have traceability system for product in operation ? untuk produk, isi No jika manufaktur tidak mempunyai
sistem mampu telusur untuk produk, isi NA jika pernyataan
tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai kebijakan penanganan

5. Is there a glass material policy in your plant, including brittle material? bahan gelas termasuk bahan brittle, isi No jika manufaktur
tidak mempunyai kebijakan penanganan bahan gelas
termasuk bahan brittle, isi NA jika pernyataan tsb tidak
applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai kebijakan pembagian

6. Is the plant divided into different hygiene zones ? zona higienis yang berbeda, isi No jika manufaktur tidak
mempunyai kebijakan pembagian zona higienis yang
berbeda, isi NA jika pernyataan tsb tidak applicable di
manufaktur tsb

Isi Yes jika manufaktur mempunyai program cleaning yang

7. Do you have documentend cleaning programs on sites? terdokumentasi, isi No jika manufaktur tidak mempunyai
program cleaning yang terdokumentasi, isi NA jika
pernyataan tsb tidak applicable di manufaktur tsb

8. Do you have CIP (Cleaning In Place) systems? Isi Yes jika manufaktur mempunyai sistem CIP, isi No jika
manufaktur tidak mempunyai sistem CIP, isi NA jika
pernyataan tsb tidak applicable di manufaktur tsb
9. Do you have pest control plan documentation (insect, rats, birds…) ? Isi Yes jika manufaktur mempunyai program pest control
yang terdokumentasi, isi No jika manufaktur tidak
mempunyai program pest control yang terdokumentasi, isi
NA jika pernyataan tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai program dan panduan

10. Does a guide and documented procedure for personnel hygiene exist personnel hygiene yang terdokumentasi, isi No jika
manufaktur tidak mempunyai program dan panduan
personnel hygiene yang terdokumentasi, isi NA jika
pernyataan tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai prosedur 'crisis

11. Does a crisis management procedure exist and relevant persons trained ? management' dan mempunyai orang-orang yang terlatih, isi
No jika manufaktur tidak mempunyai prosedur 'crisis
management' dan tidak ada orang-orang yang terlatih, isi
NA jika pernyataan tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai prosedur dan

menjalankan panduan program food defense dan food fruad,
12. Does a recall procedure exist ?
isi No jika manufaktur tidak mempunyai prosedur dan tidak
menjalankan panduan program food defense dan food fruad,
isi NA jika pernyataan tsb tidak applicable di manufaktur
tsb

Isi Yes jika manufaktur mempunyai prosedur recall/

13. Does a guide and documented procedure for Food Defense and Food Fraud ? penariakan produk, isi No jika manufaktur tidak
mempunyai prosedur recall/ penariakn produk, isi NA jika
pernyataan tsb tidak applicable di manufaktur tsb

Isi Yes jika manufaktur mempunyai panduan dan prosedur

14. Does a GMP guide and documented procedures exist ? GMP yang terdokumentasi, isi No jika manufaktur tidak
mempunyai panduan dan prosedur GMP yang
terdokumentasi, isi NA jika pernyataan tsb tidak applicable
di manufaktur tsb

Isi Yes jika manufaktur menerapkan HACCP di semua

15 Is there an HACCP plan implemented for all process ? proses, isi No jika manufaktur tidak menerapkan HACCP di
semua proses, isi NA jika pernyataan tsb tidak applicable di
manufaktur tsb

No. Kode Dok :

KBU/FO/QAD/19/059
PT KOBE BOGA UTAMA Tingkatan Dok : IV
Status Revisi : 02

Quality & Food Safety SUPPLIER FOOD SAFETY VISA Tgl. Mulai Berlaku : 21 Maret 2019
Department (Raw Material) Halaman : 4 dari 4

H. DECLARATION OF GENETICALLY MODIFIED ORGANISMS

Is there any material comes from plant(s) below:

Material Yes No
Corn
Soya
Grape Seed Oil

Cotton Isi : Yes jika pada produk terdapat material yang berasal
dari tanaman tsb
Radish
Raw Rice
Potato

Papaya Isi : No jika pada pada produk tidak terdapat material yang
berasal dari tanaman tsb
Tomato
Wheat
Linseed
Eggplant

If yes, please attach free of GMO guarantee letter Jika pada produk terdapat material pada table tsb,
lampirkan surat jaminan/ statement letter free GMO

G. CHEMICAL CONTAMINATION
YES NO NA

Isi : Yes jika pada produk mengandung atau ada

Is there any heavy metal and contaminated metal examination on supplied product? kontaminasi metal, isi No jika pada produk tidak
mengandung atau tidak ada kontaminasi metal, isi NA jika
pernyataan tsb tidak applicable di produk tsb
If applicable, please specify the table below :
Heavy
Result Year
metal/chemical
Pb
Hg
As
Sn Jika pada produk mengandung atau terdapat kontaminansi
Cd metal, maka isi hasil analisa dan tahun dilakukan analisa
Pesticide
Aflatoxin
H. PACKAGING MATERIAL
1. What type of material that has been used for packaging supplied product?
Primary Packaging : Isi tipe material packaging primer dari produk tsb
Secondary Packaging : Isi tipe material packaging sekunder dari produk tsb
YES NO NA

Isi : Yes jika packaging material produk tersertifikasi food

2. Has packaging material been certificated of Food Grade? grade, isi No jika packaging material produk tidak
tersertifikasi food grade, isi NA jika pernyataan tsb tidak
applicable di produk tsb

Isi : Yes jika packaging material telah dilakukan tes migrasi,

3. Had migration test been done ? isi No jika packaging material produk tidak dilakukan tes
migrasi, isi NA jika pernyataan tsb tidak applicable di
produk tsb

If yes, please attach laboratory result of migration test result

Lampirkan hasil tes migrasi jika telah dilakukan tes migrasi

APPROVAL
Supplier Name : QFS : PT Kobe Boga Utama
Name : Name : Cahyo Noviarso
Title : Title :
Date : Date :
Signature and Stamps