Fillable Existing fixed food premises (Department of the Environment and Energy)

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Existing fixed food premises (Department of the Environment and Energy)

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Public Health Page 1 of 3 June 2021
Postal Address Customer Response Department Internet
PO Box 159 Ph: 07 3205 0555 www.moretonbay.qld.gov.au
Caboolture QLD 4510 mbrc@moretonbay.qld.gov.au
Fees listed are applicable 1 July 2021 – 30 June 2022 ABN: 92 967 232 136
Applicants must complete the sections outlined below. Applications can take up to 30 days to process.
The licence term is to 30 September. Renewal notices will be issued annually.
Application type and fees:
Existing licence - change of ownership or change of licensee
Application fee - $180.00
Please note: A pro-rata licence fee will also apply to this application. You will be notified of the fee once the licence has been assessed.
Licence fee must be paid prior to the issue of the licence and commencement of trading.
Section A - Applicant details
If applicant is an individual - complete Section A1 If applicant is a company - complete Section A2
If applicant is an Incorporated Association - complete Section A2
Section A1.- Individual application
.
First name:
Surname:
Address (not a PO Box):
Postal address:
Email address:
Home number:
Mobile phone:
Work phone:
Section A2. - Company or Incorporated Association application
A business name, trust, shop name, partnership or unincorporated company is not considered a legal entity.
Legal entity name:
ABN:
ACN:
Email address:
Registered address (not a PO Box):
Companies
- registered address
Incorporated Associations
- nominated address as
registered with ASIC
Postal address:
Contact person name:
Business number:
Mobile phone:
Work phone:
Food business licence - change of ownership
Existing fixed food premises
Page 2 of 3
Section B - Details and location of food business
Existing food business licence number:
Existing food business licensee name:
Existing licensee ABN:
Existing licensee ACN:
Existing shop trading name:
Address of existing food business:
Section C - New details of food business
Food business trading name:
Section D - Description of the food business activities
(Attach a copy of the menu or a list of proposed foods):
Identify each of the following categories that apply to this application:
Accommodation meals Delicatessen Dry bakery patisserie Food manufacturer/packer
Beverage manufacturer Food shop Café/restaurant Fruit & veg processing
Care facility meals Hospital meals Caterer - off site Mobile food business
Caterer - on site Takeaway Child care centre meals Other - please specify below
Section E - Suitability of person to hold a licence
What skills and knowledge regarding the sale of safe and suitable food does the applicant possess?
Attach copy of certificates or other supporting documentation
1. Have any of the applicants been convicted for a breach of any food legislation?
No Yes – If yes, please attach details.
2. Have any of the applicants previously held a licence under the Food Act 2006, Food Act 1981 or a corresponding law
that was suspended or cancelled?
No Yes – If yes, please attach details.
3. Have any of the applicants previously been refused a licence under the Food Act 2006, the Food Act 1981 or a
corresponding law?
No Yes – If yes, please attach details.
Note: If the applicant is a corporation or an incorporated association, the three questions above also apply to an executive
officer of the corporation or a member of the association’s management committee.
Page 3 of 3
Section F - Nomination of Food Safety Supervisor
The Food Act 2006 requires all food businesses to have a suitably qualified food safety supervisor. Council will require
evidence of the qualifications for your nominated food safety supervisor dated within the last five years. Complete
the section below and attach details of qualifications/competencies that correlate with those recommended by Queensland
Health for Food Safety Supervisors.
First name:
Surname:
Postal address:
Business number:
Mobile phone: Work phone:
Email address:
Have qualifications been attained?
Yes – Attach a copy of the certificate of attainment
No – A copy of the certificate of attainment must be forwarded to council when available.
Section G - Customer Summary
I hereby certify that I have completed all required sections of the application form, attached all supporting information, and
have paid the applicable fee as nominated on this form.
Disclaimer: Should approval be given to this application such approval will not extend to approving any other statutory or
Local Government requirements relating to this premises.
NOTE: If form is not completed correctly, council may refuse application.
Signature:
Date:
Office use only
Receipt number: _______________________________ Amount: ____________________ Date: ________________________
CSO: _____________________________ Application number: __________________________________________________
Privacy statement
Moreton Bay Regional Council is collecting your personal information for the purpose of assessing your application for a food business
licence. The collection of this information is authorised under the Food Act 2006. Council will use your personal information to update
council’s customer information records and to contact you about other functions and services of council.
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Existing fixed food premises (Department of the Environment and Energy)

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Completed 1 June 2022

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