Application for Renewal of Off-Licence
(Section 127, Sale and Supply of Alcohol Act 2012)
General information:
An application for renewal of off-licence must be filed at least 20 working days before the
licence is due to expire.
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
the layout of the interior of the premises
CCTV placement and security lighting (if applicable).
For supermarkets and grocery stores only: the single area where alcohol will be displayed must
be clearly shown
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
For grocery stores only: A statement of 12 months sales figures (verified by an accountant)
establishing the range of good sold (as required by regulations 12/13 of the sale and Supply of
Alcohol Regulations 2013)
Copies of any proposed advertising or promotions (if applicable)
If you are applying for the renewal of off-licence on behalf of someone else:
A copy of the authority to act as an agent of the applicant, signed by the applicant
Send the completed application form and attachments to:
Liquor Licensing Department
Matamata-Piako District Council
PO Box 266
Te Aroha, 3342
Application for Renewal of Off-Licence
(Section 127, Sale and Supply of Alcohol Act 2012)
To the Secretary
District Licensing Committee, Matamata Piako District Council
Application for renewal of off-licence is made in accordance with the details set out below.
Applicant details
Full legal name to appear on licence:
(the licensee, i.e. the person or organisation that the proceeds from alcohol sales are going to):
Date of birth (if the applicant is an individual):
Occupation (if the applicant is an individual):
Status of applicant:
Individual person
Licensing trust or community trust
(advise what authority under which incorporated)
Private company
Public company
Local authority
Postal address (for service of documents):
______________________________________________ Postcode:
Home phone:___________________________ Work phone:
Mobile phone:
E-mail address:
Daytime contact details (if different from above)
Phone number: _________________________ Mobile number:
E-mail address:
Does the applicant (or any company directors) 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
Further details where applicant is a company:
Date and place of incorporation:
State the full details of each director:
Date of birth
Place of birth
If applicant is a private company, state the full details of each person who holds any shares issued by
the company:
Shareholder 1
Shareholder 2
Shareholder 3
Shareholder 4
If applicant is a public company, state the full details of each person who holds 20% or more of the shares,
or of any class of shares, issued by the company:
Shareholder 1
Shareholder 2
Shareholder 3
Shareholder 4
Further details where applicant is a partnership
State the full details of each partner:
Partner 1
Partner 2
Partner 3
Partner 4
Date of birth
Place of birth
Regarding the above company/partnership details, have there been any changes since the issue of the
licence or last renewal? If so, what are those changes?:
Premises details
Address of proposed licensed premises:
Trading name:
Does the applicant own the proposed 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?
Business details
What is the general nature of the business conducted by the applicant under the licence?
(e.g. hotel, tavern, supermarket, grocery store, wholesaler, alcohol retailer, other)
Is the sale of alcohol the principal purpose of the business?
Yes No
If NO, what is the principal purpose of the business?
On which days and during what hours is alcohol sold under the licence?
Is any endorsement sought, or sought to be renewed?
Auctioneer (Section 39)
Yes No
Remote sales (Section 40)
Yes No
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)?
To what extent, and where, is drinking water freely available to patrons for tastings?
What steps are taken to ensure that the requirements of the Act in relation to the sale and supply of
alcohol to prohibited persons are observed?
What steps are in place 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 site plan would assist):
State the number of residential neighbours within a 50m radius of the premises:
What security systems are in place (e.g. lighting, indoor/outdoor CCTV) and where?
Can the entire premises be seen from the service counter?
Yes No
If 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?
Does the lighting outside the premises discourage loitering? Does the lighting allow staff to
check IDs etc? Please describe:
Will security staff be employed? Yes No
If YES, when will the security staff be used?
What formal registration or qualification (such as Certificate of Approval) do security staff have?
Are you involved in any mystery shopper/pseudo controlled purchase operation programmes?
Yes No
IF YES, please state details:
Will there be till prompt systems regarding age checks?
Yes No
What staff training will be provided regarding compliance with the Act and host responsibility practices?
Explain what was taught regarding the sale and supply of alcohol, what staff and how often. Please
provide written records.
Explain fully your intentions regarding advertising and promotions. This should include information such
as the number of promotions, where, size, relative to what products and the proposed % discounts.
Shop windows or on the building:
Street and or footpath signage:
Social media:
Newspapers and magazines:
What is the policy regarding pricing and promotions of alcohol?
Will there be any single sales of any alcoholic products in containers less than 750mls?
Yes No
IF YES, please state details:
Have you had any complaints from the neighbours (including confirmed noise complaints) that you are
aware of?
Has your business been subject to police controlled purchase operations and if so, what were
the results?
Have you or any related businesses appeared before the Alcohol Regulatory and Licensing Authority
for any reason?
Yes No
If YES, please provide details:
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.
Applicant name: Designation:
Signature: ___________________ ________ Date:
Contact us:
Phone: (07) 838 6633
Location: 35 Kenrick Street, Te Aroha
(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
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
Supermarket, grocery store, bottle store
Hotel, tavern
Club, remote sale premises, other
Winery cellar doors
Latest trading hour allowed by licence
10:00pm or earlier
Any time after 10:00pm
Remote sales premises
Number of enforcement holdings in last 18 months
2 or more
Your weighting:
Enforcementhas 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 inclusive.
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 If you need
assistance calculating your fees, please contact us on the details below.
Contact us:
Phone: (07) 884 0060
Location: 35 Kenrick Street, Te Aroha