Food Premises Registration Form

FOOD PREMISES NEW PREMISES REGISTRATION / CHANGE OF EXISTING

REGISTRATION New Business or Change of Proprietor or Change of Trading Name or Other ……………………………………………………………………………………………… Please tick

Food Act 2003 - Food Premises Notification & Notification Fee $58.50 A food business must have the appropriate Development Consent and notify both Council and NSW Food Authority prior to commencing any food handling operations:

Bayside Council – By completing this registration form NSW Food Authority – By completing a notification online at www.foodnotify.nsw.gov.au

Food Premises Proprietor Details (Please Print) (If more than 1 proprietor, please tick box and add details in “Additional Information” Page 2.) Surname: First Name: Company Name: (if applicable) Address: Suburb: Post Code: Mailing Address: Suburb: Post Code: Phone (m): Phone (w): Fax: ABN / ACN: Email:

Food Premises Details Name of Food Business: Primary Type of Food Business: Contact Person: Address: Suburb: Post Code: Mailing Address: Suburb: Post Code: Phone (m): Phone (w): Fax: ABN / ACN Email:

Food Premises Registration Form

Types of Food Premises

Please select the most relevant type of food business: Restaurant Café Take away food / drinks Supermarket General Store Chicken / poultry retail Delicatessen Service station Licensed Club / restaurant Baker Ice cream Child care centre Seafood – retail Food caterer Canteen / kiosk Other ………………………………………………………………………………………………………………………………………………………… Operating / business hours

Please select appropriate option: Day-time operation Day and night-time operation Night-time only operation Details of Food Safety Supervisor

Food Safety Supervisor Name: …………………………………………………………………………………………………………………………………… Certification Number: ………………………………………………………………………………… Date issued: ……………………………………….. Copy of Certificate provided to Council Development Consent or Complying Development Certificate Details (where applicable)

Application Number: …………………………………………………………………………………. Date of Issue: ………………………………………. ADDITIONAL INFORMATION

Please Note Council may inspect the business without prior notice to assess the business for compliance with legislative requirements. An inspection fee may be charged. See Council’s Food Surveillance Strategy for more information. To view the Food Standards Australia and New Zealand (FSANZ) Food Standards Code, please refer to the FSANZ website: www.foodstandards.gov.au

Signature Applicant Signature: Date:

Food Premises Registration Form

HOW TO LODGE THIS REGISTRATION & PAY FEES Fees may be paid over the Counter at Council with payment made via cash, cheque, money order, debit card and the following credit cards: Visa and Master card. OR Make your cheque or money order payable to Bayside Council and mail this form together. Do not send cash in the mail. If lodging multiple Registrations, a separate payment must be made for each registration form. Registration fees are in accordance with Council's Fees and Charges. For Official Use Only: Account Number: RC 15050 # APPLICABLE REGISTRATION FEE MUST BE ACCOMPANIED WITH THIS FORM # Registration received by: …………………………………………………………… Date: …………………………………………………………. Referred to: ………………………………………………………………………………. Date: …………………………………………………………. Receipt No: ………………………………………………………………………………. Date: …………………………………………………………