SASOA Pack 2 - Application for OFF LICENCE Or Renewal of OFF LICENCE

SASOA Pack 2 - Application for OFF LICENCE or renewal of OFF LICENCE

Information Sheet/Checklist /
1) Required Application Documentation (Complete the checklist)
⃝ New / ⃝ Renewal / ⃝ Renewal (Variation) / Office Use Only
⃝ / ⃝ / ⃝ /

1. Complete the Cost/Risk Evaluation calculate application fee

/ Application ID:
⃝ / - / - /

1. annual fee (based on cost/risk rating for application fee)

⃝ / ⃝ / ⃝ /

1. Complete Form 4 (Application for off-licence or renewal of off-licence)

⃝ / ⃝ / ⃝ /

1. Check all attachments in Part 5 of Form 4 are included

/ Date received:
⃝ / ⃝ / ⃝ /

1. A copy of your host responsibility policy and an alcohol management plan.

⃝ / ⃝ / ⃝ /

1. A letter of authorisation for the consultant, if you use an alcohol licensing consultant.

⃝ / - / ⃝ /

1. Complete the application for a ‘SASOA Planning Certificate and Building Certificate’ – NOT required for conveyances ($181.80)

/ SASOA Certificate required?
Yes No
⃝ / ⃝ / ⃝ /

1. Complete and remove Form 7 (Public Notices) from the pack. This is yours to lodge your public notices.

You must have your documentation checkedby an inspector. Applications that contain errors will be delayed. An inspector will check the fee is correct and if all the information required is there. Once you’ve completed your documentation book a pre-lodgement check.Phone (04) 237 5089 to book an appointment and specify the type of application.
2) Calculate Application and Annual Fee
Use the ‘Cost/Risk Rating Evaluation’ form (over the page) to calculate your application fee. The annual fee for new applications is payable at the time an application is lodged. For renewal applications it will be due on the anniversary of the last licence.Insert the rating, the application fee and annual fee (NEW ONLY) below.
NEW / RENEWAL / Office Use Only
Insert the total cost risk/rating → / Fees Paid
Yes No
Insert the application fee → / $ / $
(NEW APPLICATIONS ONLY) Insert the annual fee → / $ / ALARLAAnn, ALDLCAnnua
(NEW APPLICATIONS ONLY) SASOA Planning Certificate→ / $181.80 / Manual CERTS
TOTAL / $ / $
3) Lodge Your Application and Pay Your Fee
In Person(Instantly lodged)
Lodge your application during business hours at the Council Administration building – 16 Cobham Court, Porirua. / By Post (Allow three working days for lodgement)
Send your application documents and a cheque for the application fee to:
Porirua DLC, c/o Porirua City Council, P O Box 50218, Porirua, 5240
Incorrectly lodged applications will be returned to the sender.

Collection of information

The information collected on this form and relating to this application shall be used for the purpose of determining this application, any subsequent related applications under the Sale and Supply of Alcohol Act 2012 and any other matter arising under that Act. The information will be provided to the necessary reporting agencies (Police, Medical Officer of Health and the Porirua City Council Inspectorate), it will be held and processed by Porirua City Council and will be publicly available.

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1

Off Licence application pack – Sale and Supply of Alcohol Act 2012 #1599678 – July 2018

Cost/Risk Evaluation Off-licence

Insert the relevant scores from 1), 2) and 3). Add the scores together and insert the total at 4), this is your total rating. Your rating will correspond to one of the five rating ranges below and an application and annual fee.

1) Type of premises / Rating
Supermarket, grocery store, bottle store / 15
Hotel, tavern / 10
Class 1, 2 or 3 club, remote sale premises, other / 5
Winery cellar doors / 2
Insert your rating for 1) / →
2) Latest trading hour allowed by licence / Rating
10:00pm or earlier / 0
Any time after 10:00pm / 3
Remote sales (not applicable) / 0
Insert your rating for 2) / →
3) Number of enforcement holdings in last 18 months / Rating
None / 0
1 / 10
2 or more / 20
Enforcement – has the same meaning as a “Holding” under section 288 of the Act, or a previous offence for which a holding may have been issued if the offence had occurred before 18 December 2013.
Insert your rating for 3) / →
Add your ratings for 1) + 2) + 3) together and insert your total rating here / →
Total rating / 0-2 / 3-5 / 6-15 / 16-25 / 26 plus
Fee category / Very low / Low / Medium / High / Very high
Application Fee / $368.00 / $609.50 / $816.50 / $1023.50 / $1207.50
Annual Fee / $161.00 / $391.00 / $632.50 / $1035.00 / $1437.50

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1

Off Licence application pack – Sale and Supply of Alcohol Act 2012 #1599678 – July 2018

Form 4 - Sale and Supply of Alcohol regulations 2013

Application for off-licence or renewal of off licence

/
(Sections 100 and 127(2), Sale and Supply of Alcohol Act 2012)

To:The Secretary

The District Licensing Committee Porirua City Council

atPORIRUA CITY

Application for an: ⃝ Off-Licence; OR⃝ Renewal of an off-licence is made in accordance with the details set out below. The endorsements sought/sought to be renewed for this application are:

Select the most appropriate sub-category
⃝Supermarket
⃝ Grocery / ⃝ General Off Licence
⃝ Remote Sales / ⃝ Auctioneer
Is a licence already held for the premises concerned? / ⃝ No / ⃝ Yes / If yes provide Details:

1Details of Applicant

Full legal name/s of applicant to be on licence:
Trading as:
CONTACT DETAILS (Postal address for service of documents)
Address
Suburb / City, Postcode
Daytime Telephone No: / (0 ) / Fax No: / (0 )
E-mail address:
STATUS OF APPLICANT
Tick correct box
⃝ Natural Person
⃝ Public Company
⃝ Partnership
⃝ Body corporate / ⃝ Private Company
⃝ Licensing Trust
⃝ Trustee
⃝ Board, organisation or other body / ⃝ Local Authority
⃝ Government Department or other Instrument of the Crown
⃝ Manager under the protection of Personal Property Rights Act 1988
FURTHER DETAILS WHERE APPLICANT IS A NATURAL PERSON
(⃝ If multiple attach to this form)
Last Name / First Name(s)
Maiden Name / Date of Birth / .…... / .…... / ..…..
Place of Birth / Gender / ⃝ Male ⃝ Female
Occupation
Residential address
Suburb / City, Postcode
Telephone No. / E-mail address
FURTHER DETAILS WHERE APPLICANT IS NOT A NATURAL PERSON (Contact Person) Ensure you complete section 6
Name
Daytime Telephone No: / Other Number:
Website / E-mail address
FURTHER DETAILS WHERE APPLICANT IS A BODY CORPORATE
Authority under which incorporated:
BUSINESS DETAILS
Describe the applicant’s principal business and any other businesses:
APPLICANT CONVICTIONDETAILS
Has the applicant where the applicant is an individual or any director, shareholder, partner or trustee where the applicant is a company, partnership or trust been convicted of any offence in New Zealand or any other country?
⃝ Yes ⃝ No
If yes, what are the details of that person?
Last Name / First Name(s)
Maiden Name / Date of Birth / .…… / ...…. / ...….
Country of Birth / Designation
If yes, what are the details of each offence? [Record details of all convictions including date, court, offence and penalty suffered. Continue on a separate sheet if necessary].
1)
2)

2Details of Premises/Conveyance

IF NOT A CONVEYANCE
What are the full details of the applicant's proposed premises?
Address
Suburb / City
Proposed Trading Name?
Type of premises (e.g. grocery, hotel, retail shop (other than grocery),or tavern):
Is a licence sought conditional upon construction or completion of the premises?
⃝ Yes ⃝ No
Does the applicant own the proposed licensed premises?
⃝ Yes ⃝ No
If No, - What is the full name and address of the owner?
Last Name / First Name(s)
Trading As
Address
Suburb / City, Postcode
Daytime Telephone No / (0 ) / Mobile Ph No / (0 )
DETAILS OF TENURE OF PREMISES
What form of tenure of the premises will the applicant have (Including term of tenure)?
Lease, rental, other / Term of occupancy
Renewal rights
IF A CONVEYANCE
Type of Conveyance (e.g. ship, railway carriage, bus etc) / Registration number
Address of home base
(if any)
Suburb / City
Principal route travelled (if any)
Proposed trading name of conveyance (if any)
Is a licence sought conditional upon construction or completion of the premises?
⃝ Yes ⃝ No
Does the applicant own the conveyance?
⃝ Yes ⃝ No
If No, - What is the full name and address of the owner?
Last Name / First Name
Address
Suburb / City, Postcode
Daytime Telephone No.: / (0 ) / Mobile Ph No.: / (0 )
DETAILS OF TENURE OF THE CONVEYANCE
What form of tenure of the conveyance will the applicant have (Including term of tenure)?
Lease, rental, other / Term of occupancy
Renewal rights
DESIGNATION OF PREMISES/CONVEYANCE
What part (if any) of the premises does the applicant intend should be designated as follows. Identify the proposed “Restricted” or “Supervised” areas on the premises floor plan supplied with application).
(i) A restricted area
(ii) A supervised area
(iii) Is it proposed the premises be undesignated
⃝ Yes ⃝ No
3DETAILS OF MANAGERS
List the details of each manager or proposed manager

Manager 1

Last Name / First Name(s)
Date of Birth / .…… / ...…./ ...…. / Country of Birth
Daytime Telephone No.: / (0 ) / E-mail address:
Does the manager hold a current General Manager’s Certificate under the Sale and Supply of Alcohol Act 2012?
⃝ Yes ⃝ No
If yes, provide the following details;
Certificate Number: / Expiry Date / ……. / ...…. / ...….
Issued by:

Manager 2

Last Name / First Name(s)
Date of Birth / .…… / ...…./ ...…. / Country of Birth
Daytime Telephone No.: / (0 ) / E-mail address:
Does the manager hold a current General Manager’s Certificate under the Sale and Supply of Alcohol Act 2012?
⃝ Yes ⃝ No
If yes, provide the following details;
Certificate Number: / Expiry Date / ……. / ...…. / ...….
Issued by:

Manager 3

Last Name / First Name(s)
Date of Birth / .…… / ...…./ ...…. / Country of Birth
Daytime Telephone No.: / (0 ) / E-mail address:
Does the manager hold a current General Manager’s Certificate under the Sale and Supply of Alcohol Act 2012?
⃝ Yes ⃝ No
If yes, provide the following details;
Certificate Number: / Expiry Date / ……. / ...…. / ...….
Issued by:

Manager 4

Last Name / First Name(s)
Date of Birth / .…… / ...…./ ...…. / Country of Birth
Daytime Telephone No.: / (0 ) / E-mail address:
Does the manager hold a current General Manager’s Certificate under the Sale and Supply of Alcohol Act 2012?
⃝ Yes ⃝ No
If yes, provide the following details;
Certificate Number: / Expiry Date / ……. / ...…. / ...….
Issued by:

Continue on another sheet if required.

3Business Details

Is the sale of alcohol intended to be the principal purpose of the business?
⃝ Yes ⃝ No
If no, what is intended to be the principal purpose of the business?
Is the applicant engaged or intending to be engaged in the sale or supply of any goods other than alcohol or food, or in the provision of any services other than those directly related to the sale or supply of alcohol or food?
⃝ Yes ⃝ No
If Yes, what is the nature of those other goods or services?
TRADING DAYS AND HOURS
On which days and during which hours does the applicant intend to sell alcohol under the licence?
Days / Hours

4Conditions

(a)State the experience and training of the applicant:
(b)What steps does the applicant propose to take to ensure that the requirements of the Act in relation to the sale of alcohol to prohibited persons are observed?
(c)Any other steps the applicant proposes to promote the responsible consumption of alcohol?
(d)Are there any other systems (including training systems), and staff in place (or to be in place) for compliance with the Act?

5Attachments

ATTACHMENTS
Premises that are not a conveyance / Conveyance
Copy of planning certificate consent
Copies of all relevant building certificates consents
Where it must be determined whether the premises are grocery store, the statement of annual sales revenue required by regulation 12 or 13 (as the case requires) of the Sale and Supply of Alcohol Regulations 2013.
Floor plan showing—

• any proposed permitted area for the display and promotion of alcohol, and any proposed sub-areas

For body corporate applicant, copy of certificate of incorporation (or equivalent document)
Attachments required by DLC
Completed supplementary environmental questions
Completed CPTED checklist for off licence Premises
A location map showing at least a 200 metre radius around the site and the principal entrance
A written statement from the owner to the effect that the owner has no objection to the grant of the licence (only where the applicant is not the owner of the premises) / Floor plan showing each area to be designated as a supervised area or restricted area, and indicating whether supervised or restricted area.
For body corporate applicant, copy of certificate of incorporation (or equivalent document)
Attachments required by DLC
A location map showing where the conveyance will operate.
Completed supplementary environmental questions
Completed CPTED checklist for off licence Premises
A written statement from the owner to the effect that the owner has no objection to the grant of the licence (only where the applicant is not the owner of the conveyance)

6Further details where applicant is not a natural person

Companies Only

FURTHER DETAILS WHERE APPLICANT IS A COMPANY
Date of incorporation / .…… / ...…. / ...…. / Place of incorporation
A copy of the Certificate of Incorporation has been supplied with the application form? (see checklist)
⃝ Yes
Full details of each director and secretary as follows
Name / Address / Date of Birth / Place of Birth / Designation
Continue on separate page where there are more than three company directors.
(In the case only of a private company)
In the case only of a private company – full details of each person who holds shares issued by the company.
Name / Address / Date of Birth / Place of Birth / Designation / Face value of shares held
(In the case only of a public company)
In the case only of a public company – full details of each person who holds 20% or more shares, or any particular class of shares issued by the company.
Name / Address / Date of Birth / Place of Birth / Designation
Continue on separate page where there are more than three shareholders.

Partnerships Only

FURTHER DETAILS WHERE APPLICANT IS A PARTNERSHIP
Full details of each partner as follows.
Name / Address / Date of Birth / Place of Birth
1
2
3
Signature of each partner (Each partner in a partnership must sign here):
______
Partner 1 / ______
Partner 2 / ______
Partner 3
Continue on separate page where there are more than three partners.

Body Corporate Only

FURTHER DETAILS WHERE APPLICANT IS A BODY CORPORATE
Authority under which incorporated:

7Fire evacuation scheme statement (premises only)

Statement in accordance with the Sale and Supply of Alcohol Act 2012 sections 100 and 127.

(Tick the correct statement)

I the applicant state that:

⃝ / The owner of the building in which the premises are situated provides and maintains an evacuation scheme as required by section 21 B of the Fire Service Act 1975, OR
⃝ / Because of the building’s current usage, its owner is not required to provide and maintain such a scheme, OR
⃝ / Because of the nature of the building, its owner is exempt from the requirements to provide and maintain such a scheme.

8Signature (ALL APPLICANTS)

12APPLICATION FORM COMPLETED AND SIGNED BY APPLICANT
Signed and dated at: / this / day of / 20
Signature Applicant/Agent filing application / Designation
13NOTICE TO APPLICANT
1)This form must be accompanied by the prescribed fee.
2)Within 20 working days after filing this application with the District Licensing Committee (or 10 working days if it is an application for renewal), the applicant must give public notice of it in form 7. The notice must be given in compliance with regulation 36, 37, or 38 of the Sale and Supply of Alcohol Regulations 2013 (whichever applies to this application).
3)Except in the case of a conveyance, within 10 working days after filing this application with the District Licensing Committee, the applicant must ensure that notice of this application in form 7 is attached in a conspicuous place on or adjacent to the site to which this application relates (unless the Secretary of the District Licensing Committee agrees that it is impracticable or unreasonable to do so).

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1

Off Licence application pack – Sale and Supply of Alcohol Act 2012 #1599678 – July 2018

Supplementary Environmental Questions

The granting of this application will not decrease the amenity and good order of the area by more than a minor extent because we:
The design and layout of the premises complies with the Act because:
The granting of this application will contribute to the Object of the Act by:
Describe the appropriate systems, staff and training you have in place?
What is your policy regarding pricing and promotions?
What provisions are in place for the supply of free water for the duration of trading hours? And specify the locations:

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1

Off Licence application pack – Sale and Supply of Alcohol Act 2012 #1599678 – July 2018

CPTED Checklist for Off Licence Premises

WINDOWS
There isatleast50%transparencyinthefrontofthepremises / ⃝ Yes ⃝ No ⃝ N/A
There isgoodvisibilitytoandfromthepremisesandthestreet / ⃝ Yes ⃝ No ⃝ N/A
LIGHTING
Internallightinginsidethepremisesissuitable / ⃝ Yes ⃝ No ⃝ N/A
Lightingallowscustomerstobeseenastheyenterthepremises / ⃝ Yes ⃝ No ⃝ N/A
LightingallowsstafftocheckIDsetc / ⃝ Yes ⃝ No ⃝ N/A
Lightingoutsidethepremisesissuitable / ⃝ Yes ⃝ No ⃝ N/A
Lightingoutsidethepremisesdiscouragesloitering / ⃝ Yes ⃝ No ⃝ N/A
Carparksandloadingbaysarewelllit / ⃝ Yes ⃝ No ⃝ N/A
Streetlightingisoutsidethepremisesandisworkingproperly / ⃝ Yes ⃝ No ⃝ N/A
INTERNAL LAYOUT
Thecashregisterispositionednearthemainentrance / ⃝ Yes ⃝ No ⃝ N/A
Thecashregisterareaisraisedtoimprovevisibility / ⃝ Yes ⃝ No ⃝ N/A
Safeisoutofpublicview / ⃝ Yes ⃝ No ⃝ N/A
Nostockdisplaysaregreaterthan1.3metres / ⃝ Yes ⃝ No ⃝ N/A
Theentirepremisescanbeseenbythecashier / ⃝ Yes ⃝ No ⃝ N/A
Thereisgoodvisibilityintocoldstores / ⃝ Yes ⃝ No ⃝ N/A
Wheretheremaybeblindspots,mirrors orCCTVareinstalled / ⃝ Yes ⃝ No ⃝ N/A
SECURITY
Doorsandwindowsarereinforced / ⃝ Yes ⃝ No ⃝ N/A
Nothingencouragesloiteringoutsidethepremises(eg noticeboardsetc) / ⃝ Yes ⃝ No ⃝ N/A
Therearenorecessedentrancestothepremises / ⃝ Yes ⃝ No ⃝ N/A
Intruderalarmisinstalled / ⃝ Yes ⃝ No ⃝ N/A
Alarmismonitoredbymonitoringcentre / ⃝ Yes ⃝ No ⃝ N/A
Panic buttonsarelinkedtointruderalarm / ⃝ Yes ⃝ No ⃝ N/A
CCTV
CCTVisinstalled / ⃝ Yes ⃝ No ⃝ N/A
CCTVispositionedtomonitorvulnerableareas / ⃝ Yes ⃝ No ⃝ N/A
Customers areawareoftheCCTVsystem / ⃝ Yes ⃝ No ⃝ N/A
Staffunderstanditsoperation / ⃝ Yes ⃝ No ⃝ N/A
STAFF
Therearesufficientnumbersofstafftoensurecontrolofthepremises / ⃝ Yes ⃝ No ⃝ N/A
Twoormoreworkersareon duty afterdark / ⃝ Yes ⃝ No ⃝ N/A
Staffarevisibletocustomersuponenteringthestore / ⃝ Yes ⃝ No ⃝ N/A
Staffgreet/acknowledgecustomersenteringthestore / ⃝ Yes ⃝ No ⃝ N/A
Adoorbuzzernotifiesstaffofcustomersenteringthestore / ⃝ Yes ⃝ No ⃝ N/A

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1

Off Licence application pack – Sale and Supply of Alcohol Act 2012 #1599678 – July 2018

Application for SASOA Compliance Certificate

(Sale and Supply of Alcohol Act 2012) /
APPLICANT'S FULL NAME & CONTACT DETAILS
Last Name / First Name
Address
Suburb / City, Postcode
Daytime Phone No.: / (0 ) / Mobile Ph No.: / (0 )
Home Phone No.: / (0 ) / Fax No.: / (0 )
PREMISES & LICENCE DETAILS
What is the Street address of the premises?
Address
Suburb / City, Postcode
Trading Name of premises:
Are these premises currently licensed? ⃝ Yes ⃝ No
Licence Number: / 046 / / / / Expiry Date / ……. / ...…. / ...….
Are you applying for a licence variation or premises re-definition for an existing licence? (if so, give details of variation/re-definition e.g. change to trading hours, building layout, vehicle movements, etc.)
NEW APPLICATION DETAILS
This is an application for a new; or renewal of an; or variation to an: (Delete as appropriate)
⃝ On-Licence⃝ Off-Licence ⃝ Club-Licence (Tick correct box)
What are the days of the week and hours during which you intend selling alcohol under the licence?
RESOURCE & BUILDING CONSENT DETAILS
Is there an existing Resource Consent?⃝ Yes ⃝ No / Resource Consent No.:
Is there an existing Building Consent?⃝ Yes ⃝ No / Building Consent No.:
Are there any current Resource Consent or Building Consent issues outstanding? (Give details of these where known)
Signed: / Date: / .…… / ...…. / ...….
Designation

Porirua City Council, P O Box 50218, Porirua, 5240 | (04) 237 5089 | 1