Checklist
Off-Licence or Renewal of Off-Licence
Sale and Supply of Alcohol Act 2012
The following must be included in your application before it can be processed.
Please tick when completed:
Fees
Fee category Application fee Annual fee
Very low $368 $161
Low $609.50 $391
Medium $816.50 $632.50
High $1023.50 $1035
Very High $1207.50 $1437.50
Completed application
Prescribed fee
Copy of the Host Responsibility Policy
Copies of Managers’ Certificates
Completed Building Evacuation Declaration (attached)
Public Notices (attached - to be checked before you can place it in the newspaper and display it on the premises)
If a grocery store, a verified statement of annual sales revenue or a statement of projected gross sales revenue (see Sale and Supply of Alcohol
Regulations 2013)
A4 or A3 to scale plan, clearly labeled, showing all of the following (for new application; renewal only if changes made to area):
The parts of the premises to be used for the sale of alcohol
The parts of the premises (if any) intended to be restricted, supervised or undesignated areas
The principal entrance
If a supermarket or grocery, include any separate areas for foodstuffs (fresh meat, fruit & vegetables, delicatessen items)
C
ertificate of Incorporation (new application)
Map showing location of premises (new application)
Copies of Planning and Building certificates (new application)
Written statement from the owner that they have no objection to the licence being granted (new application, attached)
Covering letter including any additional information relevant to this application (new application)
Photo or artist’s impression of the premises (new application)
Where the application is made under section 34 of the Act, evidence that the sale of alcohol in a premise described in section 32 of the Act would
not be economic
Where the application relates to the business of an auctioneer, a copy of the auctioneer’s licence under the Auctioneers Act 1928
IF REQUIRED:
Copy of staff training plan/systems
Security plan
CPTED (Crime Prevention Through Environmental Design) site assessment
Notes:
The applicant must be the person or entity that will
take any money from the sale of alcohol.
Additional information may be requested during the
processing period.
Applications take a minimum of 6-8 weeks to process.
Office Use Only:
Application and Annual fees are set by a cost/risk framework under the Sale
and Supply of Alcohol (Fees) Regulations 2013. Information about the fee
framework is available on your local council’s website. Fees include GST and
are non-refundable.
If it is determined that your fee category should be changed, any additional
fee must be paid before the licence is issued.
For new applications, the application fee must be paid when the form is
submitted, and the annual fee must be paid any time before the licence is
issued. For all other applications, fees must be paid when the application is
submitted.
Risk category: Fee: Payment received:
/ /
Public notices checked:
/ /
Initial:
Application
Off-Licence or Renewal of Off-Licence
Sale and Supply of Alcohol Act 2012
1 Application Details
To: The Secretary
District Licensing Committee
(Please tick one)
Carterton
Masterton
South Wairarapa
a) Application type (choose one):
New Off-Licence (section 100)
Renewal of Off-Licence (section 127(2))
Renewal of Off-Licence with Variation (sections 120 and 127(2))
3 Applicant Details
2 Endorsements
Select the endorsement(s) sought / to be renewed:
Remote sale (section 40)
Auctioneer (section 39)
b
) St
atus of Applicant:
a) Full name(s) to be on licence (Exact company name as shown on certificate of incorporation, or your full legal name):
Private Company
Partnership
Registered Limited Partnership
Body Corporate
Trustee
Territorial Authority
Public Company
Natural Person (over 20 years old)
Board, Organisation or other Body
Licensing Trust or Community Trust
Department of State (or other instrument of the Crown Manager
under the Protection of Personal and Property Rights Act 1988)
b) Variations to current licence conditions (if any):
(i
)
Which condition(s) do you want to vary (attach a separate page if necessary):
(ii) Full reasons why variation is sought (attach a separate page if necessary):
NCS No.
2
5 Further Details where the Applicant is a Body Corporate (e.g. company)
b) If a company, the full legal names of directors (attach a separate sheet if necessary):
Full Legal Name
Residential Address
Date of Birth
c) Postal address for service of documents:
e) Description of the principal business, and any other businesses:
4 Further Details where the Applicant is a Natural Person
Full Legal Name
Any Aliases (e.g. maiden name)
Residential Address
Date of Birth
Place of Birth
Occupation
Male Female
Full Legal Name
Residential Address
Date of Birth
d) Contact Details:
Name
Website
Preferred means of formal contact
f) State all criminal convictions (other than convictions for offences against provision of the Land Transport Act 1998 not contained in
Part 6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies):
No criminal convictions
Convictions - list here:
Telephone
Mobile
Mail Email
a) Act under which the Body Corporate is incorporated:
Email
3
c) Where the applicant is a private company under the Companies Act 1993, select one of the following:
Authorised Capital Paid-up Capital
d) If a private company, the full details of each person who holds any shares issued by the company (attach a
separate sheet if necessary):
Full Legal Name
Residential Address
Date of Birth Place of Birth
Face Value of Shares Occupation
e) If a public company, the full details of each person who holds 20 percent or more of the shares, or any particular class of
shares, issued by the company (attach a separate sheet if necessary):
Full Legal Name
Residential Address
Date of Birth Place of Birth
Designation
6 Further Details where the Applicant is a Partnership
Full details of each partner:
Full Legal Name
Residential Address
Date of Birth Place of Birth
Face Value of Shares Occupation
Full Legal Name
Residential Address
Date of Birth Place of Birth
Face Value of Shares Occupation
Full Legal Name
Residential Address
Date of Birth Place of Birth
Designation
Full Legal Name
Residential Address
Date of Birth Place of Birth
Designation
Full Legal Name
Residential Address
Date of Birth Place of Birth
Signature
Full Legal Name
Residential Address
Date of Birth Place of Birth
Signature
4
7 Premises Details
a) Address
b) Trading name for premises
Yes No
c) Is the licence sought conditional on completing building work?
d) Does the applicant own the proposed licensed premises?
Yes No
8 Managers’ Details
Full Name Certificate Number Expiry Date Date of Birth
9 Business Details
a) What is the general nature of the business to be conducted in the premises if the license is granted? (bottle store, tavern, winery
cellar door, remote sales, supermarket, grocery, etc.)
No Yes
b) Will the sale of alcohol be the principal purpose of the business?
If no, indicate what will be principal purpose of the business:
c) Is the applicant engaged, or intending to be engaged, in the sale or supply of 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, describe the other goods or services:
If no attach a completed building owner’s approval form (page 8 of this form)
(i) What is the full name of the owner?
(ii) What form of tenure, and term of tenure, will the applicant have? (e.g. leasehold, tenancy)
d) If you intend to do remote sales, will they be by:
Phone
Internet sales
Order form
5
e) Which days and hours do you propose to sell or supply alcohol under the licence?
f)
Is the premises a grocery store?
10 Conditions
a) Describe your experience and training in the sale and supply of alcohol:
b) Describe the steps that will be taken to prevent the sale and supply of alcohol to minors and intoxicated people:
Yes No
If yes, aach a statement of annual sales revenue detailing gross sales revenue (excluding GST) of food products, household
items, alcohol tobacco and convenience foods (confeconary, ready-to-eat prepared food, snack food, or a drink (other than
milk) sold in a container with a capacity of one litre or less) and other revenue. The Statement of sales must exclude revenu
e
s
ales from New Zealand loeries (e.g. Keno, LOTTO and Instant Kiwi).
This statement of annual sales revenue must be for a 12-month period ending no more than 90 days before the applicaon is
made. The statement of annual sales revenue is to be veried as correct, according to prepared accounts, by a chartered
accountant.
If the applicaon is for a new business (operang less than 12 months) or a business that has changed materially in the last 1
2
m
onths, the statement of projected gross sales revenue is to be for the following 12 months
.
c) D
escribe what other steps will be taken to promote the responsible consumption of alcohol:
d) Describe any other systems (including training) and staff that are, or will be, in place to comply with the Act. Attach a copy of
y
our staff training plan/systems if applicable:
6
Applications must be submitted to the local council where the premises is located:
District Licensing Committee
Masterton District Council
PO Box 444
Masterton 5840
T 06 370 6300
E alcohol@mstn.govt.nz
www.mstn.govt.nz
District Licensing Committee
Carterton District Council
PO Box 9
Carterton 5743
T 06 379 4030
E health@cdc.govt.nz
www.cdc.govt.nz
District Licensing Committee
South Wairarapa District Council
PO Box 6
Martinborough 5741
T 06 306 9611
E health@swdc.govt.nz
www.swdc.govt.nz
NOTES:
1. The New Zealand Police are required by the Sale and Supply of Alcohol Act 2012 to make enquiries into the suitability of
the applicant. This will involve the Police informing the District Licensing Committee of any convictions or concerns involving
the applicant. Should there be any concerns, the applicant will also be informed.
2. This application, including personal information, will be available to the public and media as part of the District Licensing
Committee’s decision-making process.
3. This form must be accompanied by the prescribed fee.
4. The applicant must give public notice of this application (in Form 7) within 20 working days of filing with the District
Licensing Committee (10 days for a renewal). The notice must comply with regulation 36, 37 or 38 (whichever applies) of
the Sale and Supply of Alcohol Regulations 2013.
5. The applicant must ensure that notice of this application (in Form 7) is attached in a conspicuous place on or adjacent t
o
t
he site to which this application relates, within 10 working days of filing with the District Licensing Committee. The
Secretary of the District Licensing Committee may waive this requirement if it is deemed impracticable or unreasonable to
display the notice.
Da
ted this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________
Off-Licence
7
Off-Licence
Building Evacuation Declaration
Premises name
Premises address
I HEREBY STATE THAT
The building in which the premises are situated has an evacuation scheme for public safety that meets the
requirements of Section 76 of the Fire and Emergency New Zealand 2017.
OR
The b
uilding in which the premises are situated, by reason of its current use, does not require an evacuation scheme,
or the building is exempt from having to meet the requirements for such a scheme, HOWEVER, the building does
have an evacuation procedure.
______________________________________
Building Owner’s Signature
__
____________________________________
Building Owner’s Name (print)
__
____________________________________
Date
______________________________________
Licensee Signature
__
____________________________________
Licensee Name (print)
__
____________________________________
Date
Before completing this declaration, check with Fire & Emergency NZ to ensure the building your premises are in has a Building Evacuation
Scheme. Contact the Fire Safety Officer at Fire & Emergency NZ by email evacmanagehutt-wairarapa@fire.org.nz.
7
Off-Licence
Building Evacuation Declaration
Premises name
Premises address
I HEREBY STATE THAT
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
OR
Because of the building’s current use, its owner is not required to provide and maintain such a scheme.
If you are unsure that the building has an approved evacuation scheme, check with the building owner.
For the requirements of an evacuation scheme. refer to Fire and Emergency New Zealand web site.
www.fireandemergency.nz/business-and-landlords
NOTE: Even if an approved evacuation scheme is not required, the building must have an evacuation procedure that meets
Part 1 of the Fire and Emergency New Zealand (Fire Safety, Evacuation Procedures, and Evacuation Schemes) Regulations 2018
this does not require approval by Fire Emergency New Zealand.
______________________________________
Building Owner’s Signature
______________________________________
Building Owner’s Name (print)
______________________________________
Date
______________________________________
Licensee Signature
______________________________________
Licensee Name (print)
______________________________________
Date
8
Off-Licence
Building Owner’s Approval
______________________________________
Building Owner’s Signature
_
_____________________________________
Building Owner’s Name (print)
_
_____________________________________
Date
Premises name
Premises address
If the applicant is not the owner of the building, the owner must complete this form. Required for new applications.
I HEREBY STATE THAT I have no objection to the Off-Licence being granted to allow
the sale and supply of alcohol from the above premises.
9
Off-Licence
CPTED Checklist for Off-licensed Premises
WINDOWS
There is at least 50% transparency in the front of the premises yes no n/a
There is good visibility to and from the premises and the street yes no n/a
INTERNAL LAYOUT
The cash register is positioned near the main entrance yes no n/a
The cash register area is raised to improve visibility yes no n/a
Where there may be blind spots, mirrors or CCTV are installed yes no n/a
The safe is out of public view yes no n/a
No stock displays are greater than 1.3 metres yes no n/a
The entire premises can be seen by the cashier yes no n/a
There is good visibility into cold stores yes no n/a
LIGHTING
Internal lighting is suitable yes no n/a
Lighting allows for door staff to check ID and similar yes no n/a
Lighting allows customers to be seen as they enter the premises yes no n/a
External lighting is suitable yes no n/a
External lighting discourages loitering yes no n/a
Car parks and loading bays are well lit yes no n/a
Street lighting is outside the premises and is working properly yes no n/a
CCTV
CCTV is installed yes no n/a
CCTV is positioned to monitor vulnerable areas yes no n/a
Patrons are aware of the CCTV system yes no n/a
Staff know how to operate the CCTV system yes no n/a
continued
10
CPTED Checklist continued
SECURITY
Doors and windows are reinforced yes no n/a
Nothing encourages loitering outside the premises (e.g. notice boards etc.) yes no n/a
There are no recessed entrances to the premises yes no n/a
Intruder alarm is installed yes no n/a
Alarm is monitored by a monitoring centre yes no n/a
Panic buttons are linked to intruder alarm yes no n/a
A door buzzer notifies staff of customers entering the store yes no n/a
There are sufficient numbers of staff to ensure control of the premises yes no n/a
Two ore more workers are on duty after dark yes no n/a
Staff are visible to customers upon entering the store yes no n/a
Staff greet/acknowledge customers entering the store yes no n/a
11
To be placed in the Newspaper
First Second Only
This is the publication of this notice (date) __________________________
The first publication was on (date) ____________________________
Public Notice : Off-Licence
Section 101 Sale and Supply of Alcohol Act 2012
This notice must be completed and attached to the Off-Licence application so a Licensing Inspector can check
it before it is placed in a newspaper. It is the applicant’s responsibility to advertise this notice in either the
Wairarapa Times-Age or the Wairarapa News.
of an Off-Licence in respect to the premises situated at (address):
for the
has made an application to the District Licensing Committee at:
Licensee Name
Address
Known as (business name):
Th
e general nature of the business conducted / to be conducted under the licence is (e.g. supermarket, bottle store, tavern, etc.):
Th
e days and hours during which alcohol is / is intended to be sold under the licence are:
Carterton District Council Masterton District Council South Wairarapa District Council
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,
OR
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.
The application may be inspected during ordinary office hours of the relevant District Licensing Committee where the premises is located.
Any person who is entitled to object, and who wishes to object to the grant of the application, may, no later than 15 working days after the
date of the first publication of this notice, file their objection in writing with the Secretary of the relevant District Licensing Committee:
Masterton District Council
161 Queen Street, Masterton
PO Box 444
Masterton 5840
Carterton District Council
Holloway Street, Carterton
PO Box 9
Carterton 5743
South Wairarapa District Council
19 Kitchener Street, Martinborough
PO Box 6
Martinborough 5741
The following variation(s) to the conditions of licence are sought (if applicable):
G
rant
Renewal
Renewal with variation
12
To be displayed on the premises
Public Notice : Off-Licence
Section 101 Sale and Supply of Alcohol Act 2012
This notice must be completed and attached to the Off-Licence application so a Licensing Inspector can check
it before it is displayed on the premises.
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,
OR
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.
of an Off-Licence in respect to the premises situated at (address):
for the
has made an application to the District Licensing Committee at:
Licensee Name
Address
Known as (business name):
Th
e general nature of the business conducted / to be conducted under the licence is (e.g. supermarket, bottle store, tavern, etc.):
Th
e days and hours during which alcohol is intended to be sold under the licence are:
Carterton District Council Masterton District Council South Wairarapa District Council
The application may be inspected during ordinary office hours of the relevant District Licensing Committee where the premises is located.
Any person who is entitled to object, and who wishes to object to the grant of the application, may, no later than 15 working days after the
date of the first publication of this notice, file their objection in writing with the Secretary of the relevant District Licensing Committee:
The following variation(s) to the conditions of licence are sought (if applicable):
Grant
Renewal
Renewal with variation
Masterton District Council
161 Queen Street, Masterton
PO Box 444
Masterton 5840
Carterton District Council
Holloway Street, Carterton
PO Box 9
Carterton 5743
South Wairarapa District Council
19 Kitchener Street, Martinborough
PO Box 6
Martinborough 5741
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