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Application for Special Licence (for Conveyance)

Application for a Special Licence (for Conveyance)
Section 76, Sale of Liquor Act 1989
(Form 11)
The Secretary
South Waikato District Licensing Agency
C/- South Waikato District CouncilTelephone (07) 885 0340
Private Bag 7Fax (07) 885 0718
TOKOROA 2392Email: / Fee: $64.40
Details of Applicant(s)
Full Name:
Date of Birth (if appropriate):
Postal Address for service of documents:
Name of Contact Person:
Contact Details: / Telephone: / Fax:
Email: / Mobile:
Full Name of Proposed Manager(s) (if any):
Is Manager certified? / Yes / No
Address of Proposed Manager(s):
Status of Applicant
(tick the correct box): / Private Company / Trustee
Public Company / Licensing Trust
Partnership / Government Department or other Instrument of Crown
Natural Person (an ordinary person in their private capacity)
Manager under the Protection of Personal and Property Rights Act 1988
Premises Details
Type of Conveyance:
Address of Home Base (if any):
Principal Route Travelled (if any):
Proposed Trading Name for Conveyance (if any):
Is a Licence sought conditional upon construction or completion of the conveyance? / Yes / No
Does the applicant own the conveyance? / Yes / No
If NO, name of owner:
Address:
What form of tenure of the premises will the applicant have (including terms of tenure)?
What part (if any) of the premises are you going to designate:
As a RESTRICTED area (where a person who is under 18 years is not permitted on the premises)
As a SUPERVISED area (where liquor may be sold or supplied in a supervised area to any person under 18 who is accompanied by a parent or guardian)
Purpose of Application
What is the particular occasion or event, or series of occasions or events, in respect of which the licence is sought?
When is this occasion or event, or series of occasions or events, to occur?
On which days and during what hours does the applicant intend to sell liquor under the licence?
Conditions
What provision does the applicant intend to make for the sale and supply of:
Food?
Non-Alcoholic Refreshments?
What steps does the applicant plan to take to make sure the law about selling liquor to “prohibited” persons are complied with? (This is to do with the Manager being present and posting of signs.)
Dated at / this / day of / 20
Applicant’s Signature:
Print Name:
To assist in completing this application, please see Check List on last page
For Office Use Only
Date Received: / Invoice: / Amount:
Date Paid: / Receipt No:
Notes
  1. For the matters that are to accompany this application, see Regulation 14(2) of the Sale of Liquor Act 1989.
  2. In respect of the status of the applicant, see Section 75 of the Sale of Liquor Act 1989.

Privacy Act 1993
  1. Personal information obtained in this application is primarily for establishing applicant identity and, when this application has been granted or declined, for administration, monitoring and enforcement.
  2. The information may be released to any inquirer about the application, the refusal of the application, or in relation to the exercise of the approval of this application.
  3. The information will be held by South Waikato District Council, Torphin Crescent, Tokoroa.
  4. The information may be provided to the Medical Officer of Health or Liquor Licensing Authority, and will be used for verifying and amending the Council’s ownership and occupier records (the Rating Roll) and will be released in accordance with the Rating Powers Act 1988 and to Valuation New Zealand.
  5. You have the right to access the information and to request its correction.
  6. Disclosure of Police Information: Applicants for this Off-Licence (for Premises) are required to sign the authorisation below. Failure to allow the Police to disclose this information may result in your application not being determined.
  7. Authorisation:The Police are required to report on this application. That report may include the release of any previous convictions you may have. You will receive a copy of that report.

Do you consent to the release of this information? / Yes
Dated at / this / day of / 20
Applicant’s Signature:
Check List for Special Licence (for Conveyance) (Regulation …)
The following must be included with every application:
1.Application Fee ($63.00). / Yes
2.One copy of application. / Yes
3.Map showing location of premises (on first application only). / Yes
4.A scale plan showing:
(a)Those parts of the premises to be used for the sale of liquor / Yes
(b)Those parts of the premises (if any) intended to be designated as restricted areas or as supervised areas. / Yes
Please check list or note “N/A” (not applicable)
5.Where the Club is not the owner of the premises, a written statement from the owner, to the effect that the owner has no objection to the grant of the licence. / Yes / N/A
6.Where the applicant is a Club, and holds a Club Licence under Section 74 of the Act, the number of the Club Licence. / Yes / N/A
7.Where the applicant is made for a licence under Section 74 of the Act, identifying particulars of the On-Licence or Club :Licence held by the applicant. / Yes / N/A

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