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Before you start, let’s check that
you have everything
Read these notes before you start
lling out the form
A copy of the site plan for each address identifying physical boundaries.
The completed scope of operations description that ts your Template Food Control Plan. This is included in this
document or please submit the completed Scope of Operation form from the MPI online tool to nd where you t
https://www.mpi.govt.nz/food-safety/food-act-2014/my-food-rules/
An internal layout plan of all food rooms detailing layout of all xed appliances, plumbing, ventilation, lighting etc.
If your business is a registered limited liability company, a copy of the Company Registration Certicate.
• This form must be used when applying to Council for registration of a Food Control Plan under section 53 of the
Food Act 2014.
• A food control plan (FCP) sets out what steps a business making or selling higher-risk foods needs to take to
make safe food. You use it to identify risks, and to show how they’re being managed. Ensure that you have
the Template Food Control Plan - The Simply Safe and Suitable Template Food Control Plan and that you have
tailored this to your business. It is a requirement under the Food Act on registration to use the plan in your
operation. Details on downloading a plan can be found at https://www.mpi.govt.nz/food-safety/food-act-2014/
food-control-plans/template-food-control-plans/steps-to-a-simply-safe-and-suitable-template-food-control-plan/
• 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: https://www.mpi.govt.nz/food-safety/food-safety-registers-and-lists/
•
Please ensure that you are proactive and any building you may be using, complies with the Building Act and
District Plan rules. If you are using your home for your operation you will need to email services@qldc.govt.nz to
advise of the home use.
• 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 comlpeted to advise of
these changes.
• If you require any further assistance to help with understanding what is required, please contact the Duty
Environmental Health Officer (EHO) or the Environmental Support Team by phone on 03 441 0499.
Page 1/11 // January 2021
APPLICATION FOR
TEMPLATE FOOD
CONTROL PLAN
Under Food Act 2014
DETAILS OF THE ENTITY/PERSON APPLYING FOR THE FOOD CONTROL PLAN REGISTRATION (RECORD INDIVIDUAL
PREMISE(S) IN SECTION 5)
Please enter the details of the entity/person responsible for this Food Control Plan registration. These details will be used for
all correspondance. This contact must be the Legal Contact who is responsible for the business.
Legal name of entity / person:
Postal address:
Phone:
Email*:
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:
LEGAL NAME(S) OF
ENTITY / PERSON REGISTERING:
(e.g. registered company, partnership
or individual)
ENTITY/PERSON REGISTERING
NZ BUSINESS NUMBER(S):
Single site application
Multiple site business *
1
Multiple business application with more than one company *
2
BUSINESS:
(tick as appropriate)
SECTION 1 DETAILS
*By entering an email address you consent to being sent information and notications electronically.
*1 Multiple site business
A multiple site business is when the business has more than one address where food is prepared, stored or traded, and
you would like to register all sites under one application.
Multiple business application
A multiple business application is where there is more than one address where food is prepared, stored or traded. Each site
may be run by a different business, but one business must have overall control and responsibility for all sites’ food safety.
*2
EXPECTED DATE OF OPENING:
BUSINESS DESCRIPTION:
Please provide a brief summary about
your food business, including your
scope and what you plan to sell.
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 2/11 // January 2021
Hospital/residential care facility
Educational facilities
Bar
Mobile trading in Queenstown Lakes District
Mobile trading across other districts (as you are trading outside QLDC
you will need to complete a verication agreement)
Other (please state)
This section provides information about what type of business you have. Please tick the food sectors you operate in below (those that
apply to all your sites) and then ensure you ll in the attached Scope of Operations document. Alternatively, you can download the
Scope of Operations form from the New Zealand Safety/Template Food Control Plan webpage.
Restaurant/café
Takeaway
FOOD SECTORS I OPERATE IN:
(tick as appropriate)
SCOPE OF OPERATIONSSECTION 2
Food Service Businesses
On or off-site caterer
Fishmonger
Delicatessen
Confectioner
Dairy
Other (please state)
Supermarket
Bakery
Food Retail Businesses
Butchery
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 3/11 // January 2021
Please add your premise 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
SITE TRADING
NAME, IF ANY
(i.e. ‘Trading As’)
SITE DAY-TO-DAY
MANAGER POSITION
STREET/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:
PREMISE INFORMATIONSECTION 3
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 4/11 // January 2021
1. I am authorised to make this application as the operator or a person with legal authority to act on behalf of the
operators listed in section 2; and
2.
The information supplied in this application is truthful and accurate to the best of my knowledge and belief; and
3. Every operator of the food businesses covered by the Food Control Plan is resident in New Zealand within the
meaning of section YD 1 or YD 2 (excluding section YD 2(2)) of the Income Tax Act 2007; and
4.
Every operator of the food businesses covered by the Food Control Plan is able to comply with the requirements
of the Food Act 2014.
5. I have read and I agree to the Food Business verication terms and conditions.
I conrm that:
APPLICANT STATEMENT
FINAL CHECK AND DOCUMENT PACKAGE TO SEND TO COUNCIL
COLLECTION OF INFORMATION
SECTION 4
SECTION 4
SECTION 5
Complete for all applications. We accept PDF or scanned versions of signatures.
Have you:
COLLECTION OF PERSONAL INFORMATION
Pursuant to Principle 3 of the Privacy Act 1993, we advise that:
• This information is being collected for the purpose of registering under the Food Act 2014; and
• The recipient of this information, which is the agency that will collect and hold the information, is QLDC; and
• Some of the information collected will be displayed on a public register; and
• The collection of information is authorised under section 53 of the Food Act 2014. The provision of this information is
necessary in order to process an application for registration under section 53; and
• The supply of this information is voluntary; however, failure to provide the requested information is likely to result in a
return of this application form, and may ultimately result in a refusal to register, in accordance with section 54 and 57 of
the Food Act 2014; and
• Under Principles 6 and 7 of the Privacy Act 1993, you have the right of access to, and correction of, any personal
information that you have provided.
COLLECTION OF OFFICIAL INFORMATION
All information provided to MPI is ofcial information and may be subject to a request made under the Ofcial Information
Act 1982.
If a request is made under that Act for information you have provided in this application, MPI must consider any such
request in accordance with its obligations under the Ofcial Information Act 1982 and any other applicable legislation.
NAME:
SIGNATURE:
JOB TITLE:
DATE:
Filled this form in completely and legibly
Attached a description of your scope of operations
Included payment of registration fee
Please send me an invoice for the registration fee
Attached copies of site plans and internal plan
Read and signed the Applicant Statement
Attached company registration if applicable
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 5/11 // January 2021
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 6/11 // January 2021
What does ‘Scope of Operations’ mean?
The term ‘Scope of Operations’ is used to describe the activities 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.
SCOPE OF OPERATIONS
TEMPLATE FOOD CONTROL PLAN BUSINESS
Why do I need to complete a ‘Scope of
Operations’?
If you are operating 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 application for registration to your local council or MPI.
HOW DO YOU SOURCE AND SUPPLY YOUR PRODUCTS/SERVICES?
Tick all the trading operations that your business is involved in.
Caterer
Provides food, supplies and services for a social
occasion or function or within an education or
other facility
TRADING OPERATIONSSECTION 6
Eat-in premises
Examples: restaurant, café, residential care,
early childhood education (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
Online selling of food products
Market
Example: stall at a farmers’ or other market
Mobile
Example: food truck
On-licence
Eat-in premises that sell alcohol for consumption
at the same location
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
consumption at another location
Transport provider
Ambient or temperature-controlled transport
Wholesale
Premises selling to retailers
WHAT PROCESSES DO YOU USE IN YOUR FOOD BUSINESS?
Acidication
Using acid (low pH) to preserve food products.
Examples: mayonnaise, pickles and shelf stable
conditments
PROCESSESSECTION 7
Fermentation
Using micro-organisms to make or preserve
food products.
Examples: kimchee, sauerkraut, pickles
Handling chilled RTE products
Handling chilled ready-to-eat (RTE) products
with a shelf-life of more than 5 days.
Example: sliced cooked ham
Holding at serving temperature
Holding at serving temperature in a pie warmer
or bain-marie
Reheating
Reheating a food that has been previously
cooked for immediate consumption. Example:
reheating a frozen cooked ready-to-eat meal
Slow or low temperature cooking
Examples: sous vide, hangi, umu and smoking
None of the above
None of the above processes are used
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 7/11 // January 2021
FOOD SERVICESECTION 8
SERVE/SELL FOOD DIRECTLY TO CUSTOMERS TO BE EATEN STRAIGHT AWAY.
DO YOU PRODUCE FOOD TO BE SERVED OR SOLD DIRECTLY TO CUSTOMERS?
Ready-to-eat meals and snacks
Examples: restaurant meal, catered food, take-
away, sandwiches, pie, lled roll, smoothies,
milkshake and fresh juice. If you are doing any
of the other foods listed here, also tick them.
Chinese-style roast duck
Doner meat
Meals or snacks made using doner meat.
Examples: kebab and wrap
Minimally processed fruits and vegetables
Example: washed apples
Sushi
Sushi rolls and sashimi
2
10
50
40
20
30
Tick all the activities your business does, and the products you work with.
DO YOU?
Baked products (without lling or icing)
OPERATIONSSECTION 9
Baked products, with lling or icing
Dairy products
Eggs
Infant formula
Examples: infant formula, follow-on formula and
infant formula products for special dietary use
Minimally processed fruit and vegetables
Examples: washed apple and trimmed beetroot
Processed fruit and vegetables
Processed meat, poultry and seafood products
Raw meat, poultry and seafood
Ready-to-eat meals and snacks
Sauces, soups, dressings and toppings
Shelf-stable products
Under ambient conditions. Examples: packet of
biscuits, can of tomato soup, jar of mayonnaise
SELL PRODUCTS THAT YOU PREPARE AND/OR MAKE?
70
1
80
40
10
110
50
60
30
20
90
100
120
50 120
NOTE: If all the food you make is served directly to customers you don’t need to complete the rest of the form.
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 8/11 // January 2021
Tick all the activities your business does, and the products you work with.
DO YOU?
OPERATIONSSECTION 9
Baked products (without lling or icing)
Baked products, with lling or icing
Dairy products
Example: scooping ice cream
Eggs
Infant formula
Examples: infant formula, follow-on formula and
infant formula products for special dietary use
Minimally processed fruit and vegetables
Examples: washed apple and trimmed beetroot
Processed fruit and vegetables
Processed meat, poultry and seafood products
Raw meat, poultry and seafood
Ready-to-eat meals and snacks
Sauces, soups, dressings and toppings
Shelf-stable products
Under ambient conditions. Examples: packet of
biscuits, can of tomato soup, jar of mayonnaise
SELL PRODUCTS MADE BY OTHERS?
70
80
40
10
110
50
60
30
20
90
100
120
18
Hot beverage
Examples: coffee, tea and cocoa
Processed fruit and vegetables
In manufacturer’s packaging
SELL HOT BEVERAGES AND/OR SHELF-STABLE PRE-PACKED FOOD
Food which does not require chilling or freezing
10 20
35
Ice cream Iced confectionery
Examples: ice blocks, frozen yoghurt
SELL ICE CREAM AND ICED CONFECTIONERY?
In manufacturer’s packaging
10 20
36
Infant formula
Ready-to-eat meals and snacks
PROVIDE FOOD TO PRE-SCHOOL CHILDREN?
For immediate consumption by children under 5 years of age in a centre based service setting (for example
early childhood education service centres and kōhanga reo)
20 10
22
BAKE BREAD AND BREAD PRODUCTS?
You should select this section if you bake bread and bread products only
21_010
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 9/11 // January 2021
Environmental Health – food business
verication terms and conditions
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 verification agreement. Assess each contract against
available verifiers and technical requirements, the contract will be declined if no verifier is available. 1.2 The customer may
terminate the agreement with Council at any time by giving 1 months written notice. 1.3 If the customer’s registration is
revoiked, surrendered or subsituted, 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 registration authority (if not Council and/or the Ministry). 1.4 If the customer’s registration is revoked, surrendered or
substitued, 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 verification 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 wiht the relevant provisions of the Act and Regulations. 2.1.3 The nature and extent of the
Council’s procedures and processes my 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 verification, Council will provide the food business with an outcome report for the verification
detailing whether the verification 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 verification
visit. 2.3 Council will provide the Ministry with a report on the outcome of the verification visit.
3. STANDARD OF SERVICE The Council will use its best endeavours to: > Provide the services with care and skill > Ensure
the verifier is knowledgeable and competent to verify the customer’s specific food business operations (this may include
contracting a Technical Expert to assist in the verification of the customers food business) > Provide the verification
services within a reasonable time or within any agree time limit > Provide the Outcome Report under clause 2.1.4 with 10
working days of completing the verification.
4. CONFIDENTIALITY The Council acknowledges that information held by the Council and the customer with respect to the
verification 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 Official Information
and Meetings Act 1987, the Council agrees to keep all such information and communications confidential.
5. COMPLAINTS AND DISPUTES If the customer has a complaint in relation to the Council’s verification services or the
person conducting them or the customer disputes any recommendation put forward by the verifier, 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 confidential. The customer may seek
reconsideration of a verification decision by applying to the Council in writing within 15 working days after receipt of the
verification report.
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 10/11 // January 2021
Schedule 1: Food Business verication terms and conditions continued
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, Wānaka
P:
QUEENSTOWN 03 441 0499
P: WĀNAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 11/11 // January 2021
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