Application for Renewal of Club Licence
(Section 127, Sale and Supply of Alcohol Act 2012)
Application Checklist:
Supporting documents you need to provide with your application:
Application fee. This is an application fee and is non-refundable after the application is received
by Matamata Piako District Council. (Please see information sheet on the last two pages of this
application or contact us for assistance)
Detailed A4 scale map of the interior of the premises showing:
the areas used for sale of alcohol
the areas that are to be restricted or supervised
the principal entrance
location of tables and chairs, toilets and kitchen
CCTV placement and security lighting (if applicable)
A Host Responsibility policy
Copies of each current manager’s certificate for those nominated to manage the premises
Evidence of staff training in host responsibility practices
Copy of food menu (what is available and when)
A list of alcoholic and non-alcoholic refreshments you provide
If you are applying for the renewal of club licence on behalf of someone else:
A copy of the authority to act as an agent of the applicant, signed by the applicant
The use of footpath for outdoor dining (licence to occupy, if applicable)
Send the completed application form and attachments to:
Liquor Licensing Department
Matamata-Piako District Council
PO Box 266
Te Aroha, 3342
Application for Club Licence
(Section 127, Sale and Supply of Alcohol Act 2012)
To the Secretary
District Licensing Committee, Matamata Piako District Council
Application` for renewal of club licence is made in accordance with the details set out below.
Applicant details
Full legal name of the club (the licensee):
Status of applicant:
Chartered club Sports club Social club Other
Is the club incorporated: Yes No
If YES what was the date of incorporation?
Postal address (for service of documents):
______________________________________________ Postcode:
Club secretary name: _______
Phone number: Mobile phone:
E-mail address:
Does the applicant club have any criminal convictions?
(other than convictions for offences against provisions of the Land Transport Act 1998 not contained in Part 6,
and offences to which the Criminal Records (Clean Slate) Act 2004 applies)
Yes No
If YES, please state the nature of the offence, date of conviction and penalty suffered:
Nature of the offence
Date of conviction
Penalty suffered
Premises details
Address of licensed premises:
Trading name:
Does the club own the licensed premises?
Yes No
If NO, what is the full name and address of the owner?
What form of tenure and term of tenure will the applicant have?
Club details
What is the principal purpose of the club?
What is the range of other facilities the club will offer to members, other than alcohol and food?
(e.g. Gaming - number of machines, TAB, Entertainment - types, Sports - what and how often, etc):
State the total membership of the club:
Of these, how many members are under 18 years of age?
On which days and during what hours is alcohol intended to be sold under the licence?
Duty managers details
State the full details of each manager or proposed manager:
Date of birth
Certificate number
Expiry date
What part (if any) of the premises is intended to be designated as (select at least one):
A restricted area (no one under 18 allowed on site)?
A supervised area (minors allowed only with parent or legal guardian)?
Undesignated (any age allowed)?
What provision is intended to be made for the sale and supply of food?
What provision is intended to be made for LOW alcohol (2.5% or less) and NON-alcoholic beverages?
To what extent, and where, will drinking water be freely available to patrons?
What steps does the club take to provide assistance with, or information about, alternative forms of
transport from the premises?
What steps does the club take to ensure that the requirements of the Act in relation to the sale and
supply of alcohol to prohibited persons are observed?
What steps does the club take aimed at promoting the responsible consumption of alcohol - with the
aim of minimising the harm caused by the excessive or inappropriate consumption of alcohol?
State the proximity of all sensitive sites (e.g. childcare centres, schools and churches) within a
500m radius of the premises (a map would assist):
State the number of residential neighbours within a 50m radius of the premises:
What security systems will be in place (e.g. lighting, indoor/outdoor CCTV) and where?
Can the entire premises be seen by the cashier/bar? Yes No
Where there are blind spots, are mirrors or CCTV installed? Is the internal lighting inside the premises
suitable and is there good visibility to the outdoor areas? Please describe:
Does the lighting outside the premises discourage loitering? Does the lighting allow staff to check IDs
etc? Please describe:
Will you be involved in any mystery shopper/pseudo controlled purchase operation programmes?
Yes No
If YES, please state details:
Will there be a till prompt system regarding age checks?
Yes No
What staff training will be provided regarding compliance with the Act and host responsibility
practices? Please provide a plan of what, who and when.
Does the club have a noise management plan or acoustic report? Yes (please attach) No
What soundproofing has been undertaken (if any)?
Have you had any complaints from the neighbours (including noise complaints) that you are aware of?
Has the club been subject to police controlled purchase operations and if so, what were the results?
Has the club appeared before the Alcohol Regulatory and Licensing Authority for any reason?
Yes No
If YES, please provide details:
Licence details
Are there any changes sought to the present conditions of the licence? Yes No
If YES what are the changes?
Licence number:
Expiry date:
The New Zealand police are required by the Sale and Supply of Alcohol Act 2012 to make inquiries
into the suitability of the applicant. This will involve informing the District Licensing Committee and the
Alcohol Regulatory and Licensing Authority of any convictions or concerns involving the applicant.
Should there be any concerns, the applicant will also be informed.
I consent to the release of this information
I hereby state that the above particulars are true and correct
I understand that my application will not be lodged with Council until the application fee is paid
and all required documents are supplied. Incomplete applications will be returned.
Signature: Date:
Name: ___________________________ Designation:
(Sections 100 and 127, Sale and Supply of Alcohol Act 2012)
NOTE: This declaration is to be completed, signed and returned with your application, even if
an evacuation scheme is not required.
I, licence holder (or secretary)
(full name)
of the premises known as
(trade name)
situated at
(premises address)
and which operates under a: On Off Club licence
state that:
the owner of the building in which the premises are situated provides and maintains an evacuation
scheme as required by section 21B of the Fire Service Act 1975; or
because of the building's current use, 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 requirement to provide and
maintain such a scheme
Signature: Date:
Name: ___________________________ Designation:
A registered evacuation scheme is required when:
The building can hold more than 100 people;
There are more than 10 employees in the entire building; or
Overnight accommodation is provided for more than 5 people
Please contact the NZ Fire Service for more information about evacuation schemes and fire
safety requirements.
Alcohol Licensing Fees
Club licence
The Sale and Supply of Alcohol Act 2012 has introduced national risk based fees for all alcohol
licences. The new fee system, set by the Ministry of Justice, more fairly reflects the cost of alcohol
The licence fee category is determined using the below criteria. You can use the tables below to
estimate the fee you need to pay when lodging your application.
Type of Premises
Class 1 club
Class 2 club
Class 3 club
Latest trading hour allowed by licence
2:00am or earlier
Between 2:01am and 3:00am
Any time after 3:00am
Number of enforcement holdings in last 18 months
2 or more
Your weighting:
Class 1 clubs - clubs which, in the opinion of Matamata Piako District Council, are large clubs (with
1,000 or more members of purchase age) and which, in the opinion of Matamata Piako District Council,
operate in the nature of a tavern (for example a large working men's club, combined clubs, or large
'cossie' clubs).
Class 2 clubs - clubs which do not fit class 1 or class 3 definitions (for example larger sports clubs,
medium sized RSAs, many provincial social clubs).
Class 3 clubs - clubs which, in the opinion of Matamata Piako District Council, are small clubs (with
fewer than 250 members of purchase age) and which operate a bar for 40 hours or less per week (for
example small sports clubs like bowling clubs, golf clubs, bridge clubs, and small RSAs).
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.
Application Fee
The licensing system has five fee categories, which reflect the range of cost/risk ratings. A premises' fee
category determines the application fee that the licensee has to pay.
Total weighting
Fee category
Very Low
Very High
Fee category
Total application fee
Very Low
Very High
Annual Fee
The new Act also introduces an annual fee for all licences. The annual fee is due before the licence is
issued (for new licences) and then every year on the licence anniversary date. The amount of the annual fee
you pay will be determined on the fee category and risk rating at the day the annual fee is due. You will
receive a reminder that your annual fee is due in the mail prior to the due date. All fees below are GST
Fee Category
Annual Fee
Very Low
Very High
Please note that it is Matamata Piako District Council that determines the final application and annual fees
so you may be charged further fees before your licence is granted.
All fees are set by the Ministry of Justice. For more information, see www.justice.govt.nz. If you need
assistance calculating your fees, please contact us on the details below.
Contact us:
Phone: (07) 884 0060
E-mail: customerservices@mpdc.govt.nz
Website: www.mpdc.govt.nz/our-services/alcohol-licensing
Location: 35 Kenrick Street, Te Aroha