Fillable Food Act 2014 Application for registration under (Gore District Council New Zealand)

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Food Act 2014 Application for registration under (Gore District Council New Zealand)

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Application for Registration Food Act 2014 (Form 18/13021) Version 4 / August 2018
Page 1 of 4
Application for registration under
Food Act 2014
Before you start, let’s check that you have everything you will need
The completed scope of operations document – go to http://mpi.govt.nz/food-safety/food-act-
2014/forms-and-templates
If you are applying for a National Programme (NP) registration, you can choose your verifier.
You will need a confirming letter from your verifier to attach to this application. A list of
recognised verification (or audit) agencies can be on the MPI website, under ‘registers and lists’.
The law requires Councils to verify businesses registered under the template food control plan.
If your business is a registered limited liability company, a copy of the company registration
certificate. See www.companies.govt.nz
You need to make sure you can confirm that the operator of the food businesses 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.
If you were registered with either the Ministry for Primary Industries (MPI) or your local council
before 1 March 2016, make sure you have your previous registration IDs on hand. These are
IDs such as FSA-JBIP-12345 or Licence Number: 1.
Details of payment of your application fee.
If there are any changes to the details provided in this application after
it has been sent, tell us in writing immediately.
Office use only
Date stamp
Business name:
Licence No. GDC
TRIM Ref:
Loaded into Authority
Loaded into MAPS
Fee:
Cash / Chq / Credit / DD / Eft
$140 Receipt No.
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Email info@goredc.govt.nz
www.goredc.govt.nz
Application for Registration Food Act 2014 (Form 18/13021) Version 4 / August 2018
Page 2 of 4
Collection of Information
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 MPI, PO Box 2526, Wellington 6140; and
Some of the information collected will be displayed on a public register; and
The collection of information is authorised under section 53 or section 83 of the Food Act 2014,
which ever applies. The provision of this information is necessary in order to process an
application for registration under either section 53 or section 83; and
The supply of this information is voluntary; and
Failure to provide the requested information is likely to result in a return of this application
form to the applicant, and may ultimately result in a refusal to register, in accordance with
section 54 and 57 or section 84 and 87, of the Food Act 2014, which ever applies; 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 the Ministry for Primary Industries is official information and may
be subject to a request made under the Official Information Act 1982.
If a request is made under that Act for information you have provided in this application, the
Ministry for Primary Industries must consider any such request in accordance with its
obligations under the Official Information Act 1982 and any other applicable legislation.
Application for Registration Food Act 2014 (Form 18/13021) Version 4 / August 2018
Page 3 of 4
What type of registration are you applying for?
Single site Multi-site (also need to complete and attach form 17/561)
Risk Based Measure (RMB):
Simply Safe and Suitable Template Food Control Plan
National Programme 3
National Programme 2
National Programme 1
If you were registered before 1 March 2016, what was your registration ID number?
Who is the operator of the food business?
Legal Name of Operator:
registered company partnership individual
I have attached a copy of the company name registration from the New Zealand Companies office (www.companies.govt.nz)
NZ Business Number:
If you have a New Zealand Business Number (NZBN), provide this. For more information about NZBN’s, including how to get one,
see https://www.business.govt.nz/companies
Trading Name (if any): or Same as legal name above
Operator Address and Premise Details
You must provide this information to be registered. However, if the address is a dwelling house, you may ask that the address is
withheld from the public register by ticking the box below
Postal Address:
Town: Post code:
This address is a private dwelling house and I wish it to be withheld from the public register.
Physical Address of Premises:
If different from postal address
Town: Post code:
This address is a private dwelling house and I wish it to be withheld from the public register.
Contact Person Details
The contact person details entered below will be used for communications about your registration, such as sending approval
documents and renewal reminders.
Name: Position held:
Mobile: Daytime Phone:
Email:
By entering an email address you consent to being sent information and notifications electronically, if required.
1.
2.
3.
4.
Application for Registration Food Act 2014 (Form 18/13021) Version 4 / August 2018
Page 4 of 4
All applicants to complete
Opening date (if new business): or existing business
Trading hours:
Name of day-to-day manager:
Position held:
Who will be doing your verification? Council Other
If other, insert name of verification agency:
I have attached a confirming letter from my verification agency: Yes
Have you attached the scope of operations for your business? Yes
Applicant Statement
I confirm that:
1) I am authorised to make this application as the operator or a person with legal authority to act on behalf of the
operator; and
2) The information supplied in this application is truthful and accurate to the best of my knowledge and belief; and
3) Neither I nor any directors, partners, or managers of the business concerned have been convicted, whether in
New Zealand or overseas, of any offence relating to fraud or dishonesty, or relating to management, control, or
business activities in respect of businesses of a kind (whether in New Zealand or elsewhere) that are regulated
under the Food Act 2014; and
4) The operator 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
5) The operator of the food business is able to comply with the requirements of the Food Act 2014.
Name Job title
Signature Date
Payment Details:
Payments can be made by cash, cheque or eftpos to the Gore District Council, 29 Bowler Avenue, Gore 9710 or
electronically to 03 0915 0289519 00. Please use reference FCP followed by the name of your business (ie. FCP Bob’s
Burgers)
Fees:
The application for a new registration is $140.
NOTE: Verification fees are charged separately.
Final check before sending your application to the Gore District Council
Have you:
filled this form in completely and legibly? Yes
completed and attached the Scope of Operations document? Yes
attached a letter from your verified if that is not Council? Yes NA
attached copies of company register certificates if you have a
registered limited liability company? Yes NA
read and signed the applicant statement? Yes
attached or made payment for this application? Yes
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Food Act 2014 Application for registration under (Gore District Council New Zealand)

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Completed 15 November 2020

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