Food (Forms, Exemption and Registration Details) Regulations 2005, Regulation 10

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FOOD ACT REGISTRATION - TRANSFER

Food (Forms, Exemption and Registration Details) Regulations 2005, Regulation 10

PROPRIETOR DETAILS

Surname: / First Name:
ORCompany Name:
Postal Address:
Suburb: / Postcode:
Contact Details: / BH. / Mobile:
AH. / Email:
Fax.

PREMISES DETAILS

Business Trading Name:
A.B.N. Number.
Address of Premises:
Suburb: / Postcode:

DESCRIPTION OF USE OF PREMISES

Type of Premises:
If a Food Vehicle, please provide Vehicle Registration Number:
Vehicle Make: / Vehicle Colour:
Category: /  Class 1  Class 2  Class 3
Full Time Employees: [ 2 P/T = 1 F/T ]
Is Tobacco Sold? /  Yes  No
If Yes, only from a Vending Machine? /  Yes  No
Does the premises have sit-in dining? /  Yes  No
Does the premises have a license to sell liquor? /  Yes  No

THIS SECTION BELOW TO BE COMPLETED BY THE CURRENT PROPRIETOR

Surname: / First Name:
ORCompany Name:
Postal Address:
Suburb: / Postcode:
Signature of Current Proprietor/s: / Date:

H:\Food\Template Documents\Transfers\Food Act Transfer Form 170615doc

FOOD SAFETY PROGRAM [FSP]

All Class 1 and Class 2 premises must complete a Food Safety Program (FSP). You can obtain a FSP template from Information Victoria 1300 366 356. Alternatively, you can access a computerised FSP by visiting

Type of FSP:
Please tick one only /  An approved FSP TEMPLATE requiring a Health Officer compliance check
 A NON STANDARD FSP requiring a Third Party Audit

A COPY OF A NON STANDARD FSP MUST BE SUBMITTED WITH THIS APPLICATION.

FOOD SAFETY SUPERVISOR [FSS]

All Class 1 and 2 premises must name someone to be the FSS. The FSS must have completed training to have met the requirements of the food safety competency standard. Contact the Council’s Public Health Unit for local course dates and times.

 A COPY OF THE COURSE CERTIFICATE MUST BE SUBMITTED WITH THIS APPLICATION

FULL NAME of Food Safety Supervisor:

PRIVACY STATEMENT

Council collects the personal information on this form so that it may register your premises in accordance with the Food Act 1984. This personal information is used by Council and may be disclosed to the Department of Health (Vic) in connection with the administration and enforcement of the Food Act / Public Health & Wellbeing Act 2008, but will not be disclosed to anyone else unless required to by law. Access and correction of this personal information can be made via the Public Health Unit on (03) 9205 2200.

I/We the undersigned, hereby apply to register for the current year ending 31 December under the provisions of the Food Act the premises described here and depicted in the plan lodged with the Council.

Signature: ______

The signing officer must state his/her position of authority in the case of a corporate or unincorporated body of persons, (eg. Company or Partnership).

Position: ______Date: _____ / _____ / _____

METHODS OF PAYMENT

BY MAIL /

PERSONAL PAYMENT by Cheque, Cash or EFTPOS

• Make cheques payable to Hume City Council and crossed “Not Negotiable”.

• Mail payment to:

Public Health Unit
Hume City Council
P.O. Box 119
DALLAS 3047 / Present notice intact to Cashier at:
Broadmeadows Office
1079 Pascoe Vale Rd
BROADMEADOWS
Craigieburn Office
Craigieburn Global Learning Centre
75-95 Central Park Ave
CRAIGIEBURN.
Sunbury Office
40 Macedon St
SUNBURY. / Office Hours
Monday to Friday
8.15 a.m. – 4.45 p.m.

payment details

FEE TYPE / OFFICE USE ONLY [Cashier Information] / TOTAL PAYABLE
TRANSFER of Registration / Ledger Number: GL 1000 1 64117 / $

H:\Food\Template Documents\Transfers\Food Act Transfer Form170615doc