Application for registration of premises - Tararua District Council

Application for registration of premisesPlease read this firstThis form will be scanned by electronic equipment. It is important that you:• use a blue or black pen to mark your answers; and• print clearly.Applicant details (Please print in CAPITALS)Full name of applicant(s) or company nameTrading nameAddress of premisesPostal addressTownPostcodeTelephone number Fax number Mobile number0 - 0 - 0 -EmailOther detailsManager’s nameProposed opening date Number of staff Max occupancy (for restaurants, cafes, bars, hairdressers, camping grounds)/ /General purpose of premises (please complete further details on pages 2–3)Office use onlyMedical Officer of Health approval required? Yes NoApproved, date: / / Declined HoldConditions to be imposed? Yes (please list overleaf) NoCategory classification: FP OT FD CG HDEHO:Premise numberRequires liquor inspection? Yes NoCopy to Utilities Manager: Yes, date: / / NoInspection months (please tick)Jan Feb Mar Apr May JunJul Aug Sep Oct Nov DecBuilding approval: Yes No Planning approval: Yes Notararua district council • 26 gordon street • po box 115 • dannevirke 4942 • 06 374 4080 • info@tararuadc.govt.nz

Grease trapIs there a grease trap? Yes No Is it shared? Yes NoType of trapCapacityToilet numbersUrinal stalls Male toilets Female toilets Wash hand basinsUnisex Staff only AccessibleFloor plan (New premises only)Floor plan attached of the proposed premises, detailing all floor, wall and ceiling surfaces, outdoor seating and essentialfeatures.Food safety training detailsIf you are registering food premises, please provide copies of food hygiene training certicates including name, qualification (e.g.NZQA Unit 167), and year obtained.Purpose for seeking registrationFood PremisesEatinghouse (any premises where food is prepared on thepremises for consumption on the premises)GroceryRetail sale of sandwiches, cakes or bakers smallgoodsBakery (any premises where bread, pastry, cakes orbakers’ smallgoods are baked for sale or wholesale)TakeawayRetail sale of milk and chilled dairy productsRetail sale of ice/waterRetail sale of ice-cream/frozen confectionsRetail sale of fruit or vegetablesRetail sale of meatButcherManufacturing uncooked comminuted fermented meats(UCFM)Retail sale of fish/seafoodProcessing or retail of honey and bee productsRetail sale of confectionaryDelicatessen (any premises used for the retail sale ofcooked meat, cooked pastry containing meat, meat pies,meat pasties, meat savouries, cooked poultry, cooked fish,smoked fish, fish pasties, fish savouries, quiches or similarcooked food)Manufacturer of food product(s) for retail sale elsewhere – specify type of food (continue on seperate sheet if required)OtherContinued on next page...2application for registration of premises

Purpose for seeking registration (continued)Mobile Shop – please complete an application form for a mobile shopCamping Ground – please attach a plan of the camping groundFuneral DirectorHairdresserOffensive Trade – no scale plan requiredFish cleaningRefuse collection and disposalSeptic tank desludging / disposal of sludgeStorage, drying or preserving of bones, hides, skins or hoofsCollection and storage of used bottlesApplication feeApplication fee payable $SignatureSignature of applicant or agent of business/companyDateapplication for registration of premises 3