Read these notes before you start filling out
the form
This application form must be used when applying to Council for registration of a National Programme
under section 83 of the Food Act 2014.
The National Programme is designed for lower and medium risk food businesses. It means you don't
need to use written food control plans, but you must register your business, meet food safety standards,
keep some records, and get checked. Guidance documents explain what the law requires and what
records must be kept and what a verifier will check, these can be found at https://www.mpi.govt.nz/food-
safety/food-act-2014/national-programmes/
Some information provided will be included on the public register; however, you can ask for certain
personal information to be withheld from the published register. You can view the public register here:
www.foodsafety.govt.nz/registers-lists/
Please ensure that you are proactive and that any building you may be using, complies with the Building
Act and the District Plan rules. If you are using your home for your operation you will need to email
services@qldc.govt.nz
Send the completed application form together with the other requirements above to:
Queenstown Lakes District Council, Private Bag 50072, Queenstown 9348
Or email to: services@qldc.govt.nz
If there are any changes to the details provided in this application after the application has been sent to
QLDC you must promptly inform us of the changes. There is a form on our website that must be
completed to advise of these changes.
If you require any further assistance to help with understanding what is required, please contact
Environmental Health Support or the duty Environmental Health Officer (EHO) by phone on 03 441 0499
Page 1/4 // Nov 2019
APPLICATION FOR
NATIONAL
PROGRAMME 1
Under Food Act 2014
Before you start, lets check that you have
everything you need:
A copy of the site plan for each address identifying physical boundaries.
An internal layout plan of all food rooms detailing layout of all fixed appliances, plumbing, ventilation,
lighting etc.
The completed S
cope of Operations description that fits your National Programme level. This is
included
in this document or please submit the
completed Scope of
Operation form
from the
MPI online tool, to
find where you
fit
https://www.mpi.govt.nz/food-safety/food-act-2014/my-food-rules/
If your business is a registered limited liability company a copy of the Company Registration
certificate
NP1
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Name:
I have attached a copy of the letter conrming my nominated
Verication Agency. A copy of your National Programme registration
approval and certicate will be emailed to your nominated third party
auditor once approved.
NAME OF VERIFICATION
AGENCY:
(QLDC may contact your
Verification Agency directly to
clarify any issues related to your
registration)
VERIFICATION AGENCY DETAILS (IF NOT QLDC)
SECTION 2
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 2/4 // / Nov 2019
NP1
DETAILS OF THE ENTITY/PERSON APPLYING FOR THE NATIONAL PROGRAMME REGISTRATION (RECORD SITE
DETAILS IN SECTION 5)
Please enter the details of the entity/person responsible for this registration. These details will be used for all
correspondence. This contact must be the Legal Contact who is responsible for the business.
Legal name of entity / person:
Postal Address:
Phone:
[If you have New Zealand Business Numbers (NZBN), provide them here.
If you want more information about NZBN’s, including how to get one, see
www.business.govt.nz/companies/learn-about/nzbn]
Please provide your NZBN:
Single Premises Company
Multiple Premises Company
*By entering an email address you consent to being sent information and notifications electronically
Email:
*
SECTION 1
DETAILS
BUSINESS LEGAL STATUS:
(tick as appropriate)
LEGAL NAME(S) OF
ENTITY / PERSON REGISTERING:
(e.g. registered company, partnership
or individual)
ENTITY/PERSON REGISTERING
NZ BUSINESS NUMBER(S):
BUSINESS DESCRIPTION
Please provide a brief summary
about the size and scope of your
food business and what you plan
to sell
Please add your site details - whether single or multi. Include all addresses where food is handled.
E.g. ABC Foods Limited E.g. Alphabet Café & Bar
E.g. 123 Fake Road, Faketown 1234
REGISTERED COMPANY NAME OR
INDIVIDUAL DETAILS
TRADING NAME, IF ANY
(i.e. ‘Trading As’)
SITE DAY-TO-DAY
MANAGER POSITION
PHYSICAL ADDRESS
(For Mobile companies state
address where based)
(Tick box if you
wish the address
to be withheld
from the public
register because
it is a private
dwellinghouse)
Name:
Name:
Name:
Name:
Name:
Position:
Position:
Position:
Position:
Position:
SITE INFORMATIONSECTION 3
Page 3/4 // / Nov 2019
P: QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
E.g. For mobile
NP1
 I am authorised to make this application as the operator or a person with legal authority to act on behalf of
theoperators listed in section 3
 The information supplied in this application is truthful and accurate to the best of my knowledge
 Every operator of the food businesses covered by the National Programme is resident in New Zealand
within themeaning of section YD 1 or YD 2 (excluding section YD 2(2)) of the Income Tax Act 2007
 Every operator of the food businesses covered by the National Programme is able to comply with the
requirements of the Food Act 2014.
 I have read and I agUee to the Food Business verification terms and conditions
I conrm that:
APPLICANT STATEMENT
FINAL CHECK AND DOCUMENT PACKAGE TO SEND TO COUNCIL
COLLECTION OF INFORMATION
SECTION 4
SECTION 5
SECTION 6
Complete for all applications. We accept PDF or scanned versions of signatures.
Have you:
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NAME:
SIGNATURE:
JOB TITLE:
DATE:
FEES SCHEDULE The Queenstown Lakes District Council fee structure can be found HERE
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 4/4 // Nov 2019
NP1
5HDGDQGVLJQHGWKH$SSOLFDQW6WDWHPHQW
Attached copies of site plans and internal layout
)LOOHGDOOUHTXLUHGform ILHOGVLQFRPSOHWHO\DQGOHJLEO\
Attached Company Registration certificate if applicable
Attached contract if QLDC is the nominated verifier, or
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Please invoice me the Registration Fee
click to sign
signature
click to edit
SIGN
 
SCOPE OF
OPERATIONS
FOR NP1 BUSINESSES
The term ‘Scope of Operaons’ is used to describe the acvies of your food
business and also includes:
the sector(s) a food business operates under the Food Act 2014,
what products a food business makes and/or sells,
how products are sourced and/or supplied,
how products are processed, if applicable, and
how products are sold.
What does ‘Scope of Operaons’ mean?
Why do I need to complete a ‘Scope of
Operaons’?
If you are operang a food business you need to tell your local council or Ministry
for Primary Industries (MPI) exactly what your business does.
What do I need to do?
Complete this form and submit it with your applicaon for registraon to your
local council or MPI.
Trading Operaons
How do you source and supply your products / services?
Caterer
Provides food, supplies and services for
a social occasion or funcon or within an
educaon or other facility.
Eat-in premises
Examples: Restaurant, café, residenal care
early childhood educaon (ECE) centres and
kōhanga reo.
Export
Home delivery
Examples: Pizza delivery, meals-on-wheels and
grocery delivery.
Import
Either as a registered food importer or through an
agent who is a registered importer.
Internet
On-line selling of food products.
Market
Example: Stall at farmers’ or other market.
Mobile
Example: Food truck.
On-licence
Eat-in premises that sell alcohol for consumpon
at the same locaon.
Retail
Examples: Supermarket, dairy or other premises
selling direct to the consumer.
Storage provider
Examples: Cold stores and warehouses.
Takeaway
Ready-to-eat meals sold for immediate
consumpon at another locaon.
Transport provider
Ambient or temperature-controlled transport.
Wholesale
Premises selling to other businesses.
Tick all the trading operaons that your business is involved in.
Acvies and products
Tick all the acvies your business does, and the products you make and sell.
Do you:
Sell hot beverages and / or shelf-stable pre-packed food?
Manufacture / make sugar or related products?
Sell ice cream and iced confeconery?
Hot beverage
Examples: Coee, tea and cocoa.
Sugar
Raw, brown, white and caster sugar.
Extract and pack honey?
Ice Cream
Food which does not require chilling or freezing.
(In manufacturers’ packaging).
35
34
36
10
20
10
10
32_010
20
20
Sugar products
Examples: Syrups (glucose), molasses, golden
syrup and treacle.
Packaged food (shelf-stable products)
In manufacturers’ packaging.
Iced confeconery
Examples: Ice blocks, frozen yoghurt
Grow and / or pack food?
Herbs & spices
Fresh herbs & spices, cut or planted.
Minimally processed fruits & vegetables
Minimal processing – is limited to rinsing,
trimming, shelling, waxing and packing. Excludes
sprouts and microgreens.
Mushrooms
Mushrooms and fungi.
Nuts, seeds & grains
Sprouts & microgreens
33
20
30
50
10
40
Transport and distribute or warehouse food?
Bulk food
Bulk food in a container for transport.
Chilled food
Frozen food
Hot food
Shelf-stable food
40
10
50
30
20
37
All businesses subject to a National Programme (all levels) have the right to choose their own verier. A verier is the
agency or person who will come and assess your business in order to demonstrate compliance with the Food Act
2014 and Food Regulations 2015.
Registration Authority
Y
our food business must be registered in order to legally operate. Most commonly, your registration authority will be
your local council if your business operates solely within one district.
If your business operates over different council districts or operates from multiple sites, the Ministry for Primary
Industries (MPI) may instead be your registration authority. Check with your local council or MPI if you are unsure
who your registration authority should be.
Choosing a Verier
You have the choice of selecting which agency you want to undertake your verications. This may be your local
council should they hold recognition or an independent (third party) organisation. A list of all recognised agencies
can be found on MPI’s website:
www.foodsafety.govt.nz/registers-lists/food-act-2014-recognised-agencies/index.htm
Conicts of Interest
If any staff or contractors of the Council have been involved in the design of the customer’s food premises or procedures,
it cannot act as the customer’s verier. The Council aims to undertake the agreed services in an independent and
impartial manner at all times.
Template Food Control
Plans registered with MPI
Certain Template Food Control Plan operators can nominate their own verifier. This includes Template Food Control plan
businesses registered as a mobile business with the base in QLDC but operate selling food outside of our district. Also, If
you are operating a multi-site business using a template FCP, and have been required to register with MPI or another
authority because you also operate outside the QLDC area, you may still choose to use QLDC as your verifier or appoint
your own third party verifier.
If you have registered a template FCP (whether modified or not) with MPI for a business required to operate a custom
FCP, QLDC is not able to offer verification of custom FCPs.
Once you have chosen your verifier, you will need to inform your registration authority of your choice. Your verifier may
ask you to complete an agreement to officially nominate them as your verifier.
Should you have any questions about choosing a verifier, please contact either Queenstown Lakes District
Council or MPI on 0800 00 83 33.
Page 1/4 // October 2018
CHOOSING
A VERIFIER
CUSTOMER DETAILS
SIGNATURES
QUEENSTOWN LAKES DISTRICT COUNCIL TO COMPLETE
SECTION 1
SECTION 3
SECTION 2
CUSTOMER NAME
CUSTOMER
NAME
QLDC
REPRESENTATIVE
DESIGNATION /
TITLE
QLDC REPRESENTATIVE
DESIGNATION / TITLE
DATE
DATE
REFERENCE NUMBER
DATE OF START
OF CONTRACT
DATE OF TERMINATION
CONTRACT
POSTAL ADDRESS
PHYSICAL ADDRESS
CONTACT PHONE NUMBER
CONTACT PERSON AND TITLE
TRADING NAME
SIGNATURE
SIGNATURE
VERIFICATION
RISK CATEGORY
EMAIL
Verication Agreement
Customer Agreement
The parties agree that Queenstown Lakes District Council will verify the Template Food Control Plan or National
Programme level 1, 2 or 3 (as applicable) on the attached Standard Terms as set out in schedule 1 of this Agreement.
NOTE: This Agreement must be completed by a person who has the authority to act on behalf of the business e.g. the owner, operator or
director, partner or other person with legal authority to act on behalf of the registered company or partnership or individual(s).
The parties conrm that they have read and agree to the standard terms and conditions of this
Agreement (attached at Schedule 1):
[ if different ]
[ print name ]
[ print name ]
[ if different ]
[ e.g. Director, Manager ]
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 2/4 // October 2018
Schedule 1: Food Business
verication terms and conditions
Queenstown Lakes District Council (“Council”) is a registration authority under the Food Act 2014 (“the Act”) for food control
plans (“the Plans”) and food businesses subject to a national programme (“the Programme”).
Under the Act, any appropriately recognised agency or person can verify a business operating under the Programme.
The Ministry for Primary Industries (“the Ministry”) has appointed Council a verier under the Act to verify businesses subject to
the Plans and the Programme.
The following terms and conditions apply to food businesses which have agreed for Council to act as their verier.
Terms used in these terms and conditions that are dened in the Act, have the meaning given to them in the Act.
1. TERM AND TERMINATION
1.1 Subject to the other provisions of these terms, the parties obligations to each other start on the start date and end on
the termination date set out in the verication agreement.
Assess each contract against available veriers and technical requirements, the contract will be declined if no verier
is available.
1.2
The customer may terminate the agreement with Council at any time by giving 1 month written notice.
1.3 If the customer’s registration is revoked, surrendered or substituted, or if the customer does not pay the Council’s
charges or meet any other responsibilities, Council may immediately suspend or restrict the services at any time.
Such activities will be reported to the registration authority (if not Council and/or the Ministry).
1.4
If the customer’s registration is revoked, surrendered or substituted, or if the customer does not pay the Council’s
charges or meet any other responsibilities, the Council may immediately stop providing any of its services to the
customer.
(a)
This right is additional to any other right or remedy the Council may have against the customer at law which
rights and remedies survive termination of this agreement.
1.5
Otherwise, where the Council has agreed to provide a service for a minimum period, it will continue providing it until
the end of that period, and will notify the customer, at least 14 days before it stops providing the service.
2. VERIFICATION
2.1 The customer agrees and acknowledges that:
2.1.1 The Council will carry out the verication function under the Act and the Food Regulations 2015 (“the
Regulations”), with respect to the customer’s food business.
2.1.2
The Council will obtain all evidence which in its discretion it requires to determine whether or not a food
business complies with the Programme and with the relevant provisions of the Act and Regulations.
2.1.3
The nature and extent of the Council’s procedures and processes may vary according to the type of business,
risk assessment, and previous compliance history and the Council will focus on what is most important for the
food safety at each type of business.
2.1.4
At the end of the verication, Council will provide the food business with an outcome report for the verication
detailing whether the verication is acceptable or unacceptable.
2.2
If any issues are discovered, Council will agree with the food business on a plan to address those issues, including
setting timeframes, and the timing of the next verication visit.
2.3
Council will provide the Ministry with a report of the outcome of the verication visit.
3 STANDARD OF SERVICE
The Council will use its best endeavors to:
>
Provide the services with care and skill
>
Ensure the verier is knowledgeable and competent to verify the customer’s specic food business operations. This
may include contracting a Technical Expert to assist in the verication of the customers food business
>
Provide the verication services within a reasonable time or within any agreed time limit
>
Provide the outcome Report under clause 2.1.4 within 10 working days of completing the verication
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 3/4 // October 2018
4 CONFIDENTIALITY
The Council acknowledges that information held by the Council and the customer with respect to the verication of the
customer’s food premises may be commercially sensitive to the customer. To the full extent permitted by law, and subject
to the Council’s obligation to comply with the provisions of the Local Government Ofcial Information and Meetings Act
1987, the Council agrees to keep all such information and communications condential.
5 COMPLAINTS AND DISPUTES
If the customer has a complaint in relation to the Council’s verication services or the person conducting them or
the customer disputes any recommendation put forward by the verier, please contact The Regulatory Manager of
Environmental Health. The Council documents all complaints in an attempt to improve its service under its Quality
Management System. All complaints are held as strictly condential. The customer may seek reconsideration of a
verication decision by applying to the Council in writing within 15 working days after receipt of the verication report.
6 CUSTOMERS RESPONSIBILITIES
6.1 The customer must advise the Council of any change of verier. This agreement can then be terminated with 1
month notice in writing to Council.
6.2
It remains the responsibility of the customer at all times to provide safe and suitable food. The verier does not
accept liability for food safety or for any losses incurred by the customer.
6.3
The customer agrees to provide Council with the following:
(a) reasonable access to the food business; and
(b) reasonable access to information and documents relating to the food business;
6.4 The customer warrants that all information and documents provided are, or will be, complete, true and accurate and
up-to-date at the time they are provided and that:
(a)
all food preparation tasks are being properly carried out by appropriate staff who have been suitably trained and
instructed; and
(b)
any restrictions or conditions place on the registration are being complied with; and
(c) they will notify Council of any further information, including any post verication events, which may have a
bearing on the verication.
7 OUR CHARGES
7.1 Verication fees are prescribed within Queenstown Lakes District Council’s fees and charges structure and are
subject to annual review and public notication through the Annual Plan process. The Council will provide the
customer with an invoice that must be paid by the 20th of the following month. Where follow up visits are required
additional fees as included in the fee structure may be incurred. Failure to attend a scheduled verication without
cancellation may also result in a charge.
Queenstown Lakes District Council fee structure can be found HERE
7.2
The Council will send invoices and other notices via email. It is the customer’s responsibility to advise Council of any
change of email address.
8 CHANGING THESE TERMS
Any changes to the terms of this agreement must be in writing.
9 DISCLAIMER
9.1 A verication under the Act does not constitute a permit, authorisation, or other permission under any other act,
regulation or bylaw. The verication report provided is based on the inspection of the accessible aspects of the
food business and represents the Council ofcer’s opinion of the observable condition of the building, facilities,
equipment and documents on the day and time of the inspection.
9.2
The verication report is prepared for the food business and the Ministry only. The food business agrees to not
disclose the verication report to any third party. The food business agrees to indemnify, defend and hold the
Council harmless from any third party claims arising out of the food business distribution of the inspection report to
any third party.
9.3
The Council’s liability for mistakes or omissions in the verication report is limited to a refund of the fee paid for the
verication.
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 4/4 // October 2018