Fillable Application for Off-Licence or (Timaru District Council New Zealand)

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Application for Off-Licence or (Timaru District Council New Zealand)

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#958701
Application for Off-Licence or
Renewal of Off-Licence
Sale and Supply of Alcohol Act 2012 – Sections 100 and 127(2)
For office use:
Premise name: ………………………………………………………………………………………………………………………………
Application no: ……………………………………………
Checked: ……………………………………………
Fee paid: $…………………………………………
Receipt no: ……………………………………………
Police: ……………………………………………
Health: ……………………………………………
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 1
Application for Off-Licence or Renewal of Off-Licence
Form 4
Sections 100 and 127(2), Sale and Supply of Alcohol Act 2012
1. Type of Application
Off-Licence – New Off-Licence – Renewal
Endorsements (if applicable):
Section 39 – Auctioneer Section 40 – Remote Sellers of Alcohol
2. Details of Applicant
Company name or full legal name(s) if individual to be on licence:
Is a licence already held for the premises or conveyance concerned:
Yes (if yes, state kind of licence):
No
Applicant status:
Natural person Trustee
Private company Partnership
Club Public company
Local authority Incorporated society
For an applicant that is a natural person or persons:
Gender: Male Female
Residential address:
Occupation:
Date of birth:
Contact number: Mobile number:
Email address:
For an applicant that is not a natural person or persons:
Contact name:
Postal address:
Contact number: Mobile number:
Email address:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 2
Business details (describe principal business, any other businesses):
Criminal Convictions
Have you (or in the case of a company – any director / partner) ever been convicted of an
offence (including traffic but not parking)?
Yes No
Note: As per the Criminal Records (Clean Slate) Act 2004, if you have no convictions in the
last 7 years, you need not declare any convictions prior to that date other than convictions
relating to imprisonment or indefinite disqualified from driving. Refer to
http://www.justice.govt.nz/privacy/clean-slate.html
If yes, give details:
Nature of offence:
Date of conviction:
Penalty suffered:
Nature of offence:
Date of conviction:
Penalty suffered:
Nature of offence:
Date of conviction:
Penalty suffered:
For a company (whether incorporated under the Companies Act 1993 or equivalent
foreign legislation), full legal names and addresses of directors:
Name:
Address:
Date of birth:
Name:
Address:
Date of birth:
Name:
Address:
Date of birth:
For a private company incorporated under the Companies Act 1993:
Authorised capital: Paid up capital:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 3
Full details of each person who holds 20% or more of the shares, or of any particular class
of shares, issued by the company:
Name:
Address:
Date of birth: Place of birth:
Designation: Face value of shares:
Name:
Address:
Date of birth: Place of birth:
Designation: Face value of shares:
Name:
Address:
Date of birth: Place of birth:
Designation: Face value of shares:
For a partnership, full details of each partner as follows:
Name:
Address:
Date of birth: Place of birth:
Signature:
Name:
Address:
Date of birth: Place of birth:
Signature:
Name:
Address:
Date of birth: Place of birth:
Signature:
3. Details of Premises
Address of premises:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 4
Any name, trading name, or name of building:
If not owned by applicant:
Tenure (state whether to be held as leasehold, or under tenancy agreement or licence):
Full legal name and address of owner:
Is the licence conditional on completion of building work: Yes No
If yes, state kind of licence:
4. Details of Conveyance
Kind (e.g. ship, railway carriage, bus etc):
Tenure (i.e. owned by applicant or operated under charter, lease or licence):
If not owned by applicant, full legal name and address of owner:
Any registration number:
Any home base address:
Any name used or proposed for conveyance:
Is licence conditional on completion of construction work: Yes No
If yes, state details:
5. Details of Managers
Manager 1:
Full legal name:
Address:
Date of birth:
Certificate number:
Manager 2:
Full legal name:
Address:
Date of birth:
Certificate number:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 5
Manager 3:
Full legal name:
Address:
Date of birth:
Certificate number:
Manager 4:
Full legal name:
Address:
Date of birth:
Certificate number:
Manager 5:
Full legal name:
Address:
Date of birth:
Certificate number:
Manager 6:
Full legal name:
Address:
Date of birth:
Certificate number:
6. Business Details
General nature of the business to be conducted by applicant in the premises if licence
granted:
Supermarket Grocery store
Tavern (across the bar) Standalone bottle store
Hotel (across the bar) Other
If other:
Is sale of alcohol intended to be principal purpose of business: Yes No
If no, intended principal purpose of business:
Is applicant engaged, or intending to be engaged, in the sale or supply of any goods other
than alcohol and food, or in the provision of any services other than those directly related
to the sale or supply of alcohol and food: Yes No
If yes, nature of other goods or services:
On which days and hours does the applicant intend to sell alcohol under this licence:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 6
7. Conditions
Experience and training of applicant:
What steps does the applicant propose to prevent the sale and supply of alcohol to
prohibited people?
What other steps does the applicant propose to take aimed at promoting the responsible
consumption of alcohol?
What other systems (including training systems), and staff in place (or to be in place) for
compliance with the Act?
Are any changes sought to the present conditions of the licence: Yes No
If yes, what changes were sought:
What are the full reasons for the changes sought:
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 7
8. Signature and Date
I acknowledge that I understand my obligations as prescribed by the Sale and Supply of
Alcohol Act 2012:
Signature of applicant:
Position:
Date:
If this form is being completed online, you will not be able, or required to sign this
form and the online lodgement will be treated as confirmation of your
acknowledgement and acceptance of the above responsibilities and liabilities and
that you have made the above representations, warranties and certification.
When complete, please email this form to the email address below.
For assistance please contact:
Liquor Licencing
Timaru District Council
2 King George Place
PO Box 522
Timaru 7940
Lodgement Email: liquoradmin@timdc.govt.nz
Phone: 03 687 7200
Payment of Fees
Please make payment at the time of lodgement to the following bank account:
Timaru District Council
02 0888 0269159 00
For new licences, please contact us for an invoice prior to lodging your application.
Reference: Invoice number (if renewal)
Particulars: Applicant name
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 8
Notes
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).
Checklist
Please read and complete this checklist BEFORE submitting the application.
Include with application form:
Photo of principal entrance.
Host responsibility policy.
Floor plan showing:
• Each area to be designated as an:
− Undesignated area (any person of any age may be present on the premises);
or
− Supervised area (persons under 18 may be present, but only if accompanied
by a parent or legal guardian. Those under 18 cannot be sold alcohol); or
− Restricted area (no person under 18 may be present on the premises)
• Principal entrance.
• Location of CCTV cameras.
•
Location of any security lighting.
Copy of menu(s).
Fire evacuation form.
In addition, new premises require:
Copies of planning consent (new applications only).
Copies of all relevant building certificate consents.
For body corporate applicant - copy of certificate of incorporation.
CPTED checklist.
Amenity and good order questionnaire.
Statement by owner of premises not objecting to issue of liquor licence
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 9
Attachment 1: Fire Evacuation Form
Sections 100(d) and 127(2)(e), Sale and Supply of Alcohol Act 2012
Premises:
Premise address:
Applicants name:
Applicants address:
Contact name:
Contact phone number:
Email address:
The applicant states that (tick one):
The owner of the building in which the premises are situated provides and maintains
an evacuation scheme as required by Section 76 of the Fire and Emergency New
Zealand Act 2017 (copy over page); 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.
Please note that this is a legal document. Any questions please contact Fire and
Emergency New Zealand at www.fireandemergency.nz or phone 03 684 1200.
Signature of applicant:
Designation:
Date:
A copy of this document may be sent to Fire and Emergency New Zealand (FENZ) for its
information.
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 10
Fire and Emergency New Zealand Act 2017
75 Relevant building defined for purposes of sections 76 to 79
(1) In sections 76 to 79, relevant building means a building or part of a building used for 1 or
more of the following purposes:
(a) the gathering together, for any purpose, of 100 or more persons:
(b) providing employment facilities for 10 or more persons:
(c) providing accommodation for 6 or more persons (other than in 3 or fewer
household units):
(d) a place where hazardous substances are present in quantities exceeding the
prescribed minimum amounts, whatever the purpose for which the building is used:
(e) providing an early childhood education and care centre (other than in a household
unit):
(f) providing nursing, medical, or geriatric care (other than in a household unit):
(g) providing specialised care for persons with disabilities (other than in a household
unit):
(h) providing accommodation for persons under lawful detention (not being persons
serving a sentence of home detention or community detention, or serving a
sentence of imprisonment on home detention, or on parole subject to residential
restrictions imposed under section 15 of the Parole Act 2002):
(i) any other prescribed purpose.
(2) However, in sections 76 to 79, relevant building does not include premises of a mission (as
defined in section 2(1)of the Diplomatic Privileges and Immunities Act 1968).
(3) In this section, early childhood education and care centre has the same meaning as
in section 310 of the Education Act 1989.
76 Owner must provide and maintain evacuation scheme for relevant building
(1) The owner of a relevant building must provide an evacuation scheme that is designed to
enable evacuation from the scene of a fire or an alarm of fire safely to a place of safety
within a reasonable time.
(2) The owner of a relevant building must maintain an evacuation scheme that has been
approved by FENZ under section 77.
(3) However, the owner of a relevant building is not required to provide or maintain an
evacuation scheme for the building if—
(a) the building is used for a purpose specified in section 75(1)(b) or (c); and
(b) the building has an automatic sprinkler system; and
(c) the owner of the relevant building notifies FENZ, in writing and in the prescribed
form (if any), that the building does not require an evacuation scheme.
(4) A person who knowingly contravenes subsection (1) or (2) commits an offence and is
liable on conviction,—
(a) in the case of an individual, to a term of imprisonment not exceeding 6 months or
to a fine not exceeding $75,000, or both:
(b) in any other case, to a fine not exceeding $150,000.
(5) In this section,—
• automatic sprinkler system means an automatic sprinkler system that satisfies the
minimum standard required by regulations made under section 192(1)(c)
• evacuation scheme means an evacuation scheme that complies with regulations
made under section 192(1)(b).
Application for Off-Licence or Renewal of Off-Licence #958701
Mackenzie, Timaru, Waimate District Licensing Committee Page 11
Attachment 2: Public Notice of Application
Form 7
Sections 101, Sale and Supply of Alcohol Act 2012
Company name or full legal name of applicant:
Has made an application to the Timaru Mackenzie Waimate
District Licensing Committee for the Issue Renewal
of an
On
Off
Club
Endorsed On
Endorsed Off
In respect of the premises situated at:
Or the (specify kind of conveyance):
Known as:
The general nature of the business conducted (or to be conducted) under the licence is:
Hotel
Restaurant
Bottle Store
Supermarket
Entertainment / Night Club
Remote Seller
Winery
Function Centre
Caterer
The days on which and the hours during which alcohol is (or is intended to be) sold under
the licence are (specify days and hours):
The application may be inspected during ordinary office hours at the office of the Timaru / Mackenzie /
Waimate District Licensing Committee at 2 King George Place, Timaru.
Any person who is entitled to object and who wishes to object to the issue of the licence may, not later
than 15 working days after the date of the publication of this notice, file a notice in writing of the
objection with the Secretary of the District Licensing Committee at Timaru District Council, PO Box 522,
Timaru 7940.
No objection to the issue of a licence may be made in relation to a matter other than a matter specified
in section 105(1) of the Sale and Supply of Alcohol Act 2012.
No objection to the renewal of a licence may be made in relation to a matter other than a matter
specified in section 131 of the Sale and Supply of Alcohol Act 2012.
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Completed 11 February 2021

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