Checklist
On-Licence or Renewal of On-Licence
Sale and Supply of Alcohol Act 2012
The following must be included in your application or it will be returned
Please tick when completed:
Completed application form
Prescribed fee
A menu with food descriptions and prices (or any other indication of the standard and style of food)
A beverage list showing beverage range and prices (alcoholic, low alcohol and non-alcoholic)
Copy of the Host Responsibility Policy
Copies of Managers’ Certificates
Completed Building Evacuation Declaration (attached)
Public Notices (attached - to be checked before you place it in the newspaper and display it on the premises)
A4 or A3 to scale plan of the premises, 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 or consumption of alcohol
The parts of the premises (if any) intended to be restricted, supervised or undesignated areas
The principal entrance
Certificate of Incorporation (new application)
Map showing location of premises (new application), or a route map for conveyances
Photo or artist’s impression of the premises or conveyance (new application)
Completed Building Owner’s Approval (new application only, attached)
Copies of Planning and Building certificates (new application only; contact the relevant council for a copy)
Covering letter including any additional information relevant to this application (new application)
IF REQUIRED:
Copy of staff training plan/systems
Security plan
Noise Management Plan (details noise sources and how they will be managed; may include an acoustic report)
CPTED (Crime Prevention Through Environmental Design) site assessment (attached)
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.
Fees
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.
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
Offi
ce Use Only
Risk category: Fee: Payment received:
/ /
Public notices checked:
/ /
Initial:
Application
On-Licence or Renewal of On-Licence
Sale and Supply of Alcohol Act 2012
1 Application Details
b) Variations to current licence conditions (if any):
b) Sta
tus of Applicant:
a) Full name(s) to be on licence (Exact company name as shown on certificate of incorporation, or your full legal name):
To: The Secretary
District Licensing Committee
(Please tick one)
Carterton
Masterton
South Wairarapa
a) Application type (choose one):
Ne
w On-Licence (section 100)
Renewal of On-Licence (section 127(2))
Renewal of On-Licence with Variation (sections 120 and 127(2))
3 Applicant Details
NCS No.
2 Endorsements
Select the endorsement(s) sought / to be renewed:
Caterer (section 38)
BYO Restaurant (section 37)
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)
(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):
2
5 Further Details where the Applicant is a Body Corporate (e.g. company)
a) Act under which the body corporate or company is incorporated:
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
) P
ostal address for service of documents:
d) Contact Details:
Name
Telephone
Email
Website
e) Description of the principal business, and any other businesses:
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):
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
Mobile
Preferred means of formal contact
Phone Email
No criminal convictions
Convictions - list here:
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
s
eparate 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
8 Conveyance Details
a) Address
b) Trading name for premises
Yes No
c
) I
s the licence sought conditional on completing building work?
d
) D
oes the applicant own the proposed licensed premises?
Yes No
(i
)
What is the full name of the owner?
(ii
) W
hat form of tenure, and term of tenure, will the applicant have? (e.g. leasehold, tenancy)
If no attach a completed building owner’s approval form (page 9 of this form)
a) Type (car, bus, etc.)
b) Trading name for conveyance
d) Is a current Warrant of Fitness and Registration (if car or bus), Safe Ship Management Certificate (if ship, ferry or hovercraft),
Ce
rtificate of Airworthiness (if aircraft) or Rail Service Licence (if a train) in effect for this conveyance?
Yes No
c) Home base address (if any)
Registration number
e) Principal route travelled
Yes No
f)
Is the licence sought conditional on completing construction work?
If yes, please provide details:
g) Does the applicant own the proposed licensed conveyance?
Yes No
(ii
) W
hat form of tenure, and term of tenure, will the applicant have? (e.g. charter)
(i
)
What is the full name and address of the owner?
If no:
9 Managers’ Details
Full Name Certificate Number Expiry Date Date of Birth
5
10 Business Details
a) What is the general nature of the business to be conducted in the premises if the license is granted? (hotel, tavern, restaurant,
cellar door, cinema, etc.)
No Yes
b
) W
ill the sale of alcohol be the principal purpose of the business?
If no,
indicate what will be principal purpose of the business:
d) Which days and hours do you propose to sell or supply alcohol under the licence?
c) I
s the applicant engaged, or intending to be engaged, in the sale or supply of goods other than alcohol and food, or in th
e
p
rovision 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:
11 Conditions
a) Describe your experience and training in the sale and supply of alcohol:
6
b) Attach a menu and beverage list that describes food and beverage types, ranges and prices.
c
) D
escribe to what extent and where drinking water will be freely available to patrons:
e) Describe the steps that will be taken to prevent the sale and supply of alcohol to minors and intoxicated people:
d) If there is no access to mains water supply, please comment on the potability of the water that will be available:
f) Describe what steps will be taken and what information will be provided to help with transport options from the licensed
premises:
g) Describe what other steps will be taken to promote the responsible consumption of alcohol:
h) Describe any other systems (including training) and staff that are, or will be, in place to comply with the Act. Attach a copy
of your staff training plan/systems if applicable:
7
Dat
ed this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________
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. Except in the case of a conveyance, the applicant must ensure that notice of this application (in Form 7) is attached in a
conspicuous place on or adjacent to the 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.
On-Licence
8
On-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
9
On-Licence
Building Owner’s Approval
I HEREBY STATE THAT I have no objection to the On-Licence being granted to allow
the sale and supply of alcohol from the above premises.
______________________________________
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.
10
On-Licence
CPTED Checklist for On-licensed Premises
BAR AREA
Bar staff have good visibility of entire premises yes no n/a
Area behind the bar is raised to improve visibility yes no n/a
Bar area is open with no obstructions affecting monitoring of premises yes no n/a
Cash registers are front facing yes no n/a
If cash registers are not front facing, mirrors are installed to monitor customers yes no n/a
Safe is out of public view yes no n/a
INTERNAL LAYOUT
Premises is laid out so staff can monitor patrons at all times yes no n/a
There are no obstructions within the bar causing blind spots yes no n/a
Where there may be blind spots, mirrors or CCTV are installed yes no n/a
Bar is easily approached by customers yes no n/a
Customers can easily move around the premises yes no n/a
Sufficient seating is provided yes no n/a
Customers cannot climb on structures or fittings yes no n/a
CROWDING
There premises are not overcrowded yes no n/a
The maximum number of patrons for the premises is displayed and complied with 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 staff to monitor patrons within the premises yes no n/a
No areas are too dark inside the premises yes no n/a
Internal lighting can be raised in an emergency/incident or at closing time yes no n/a
External lighting is suitable yes no n/a
External security lighting is installed yes no n/a
VENTILATION
A ventilation system is installed yes no n/a
The premises are maintained at a suitable temperature yes no n/a
11
CPTED Checklist continued
OUTDOOR DRINKING AREAS
Outdoor drinking areas are monitored by bar and/or security staff yes no n/a
Lighting allows staff to monitor patrons yes no n/a
Customers can move around easily in outdoor drinking areas yes no n/a
Outdoor drinking areas are well defined from surrounding environment yes no n/a
Pavement creep is not evident yes no n/a
Outdoor drinking areas are not overcrowded yes no n/a
A current street trading licence or equivalent is held 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
TOILETS
Toilet facility entrances are visible from the bar area yes no n/a
Toilets are inspected regularly yes no n/a
STAFF
There are sufficient numbers of staff to ensure control of the premises yes no n/a
Staff are visible to patrons yes no n/a
Staff monitor the premises for conflict and crime yes no n/a
Security staff are properly trained and certified yes no n/a
ENTRANCES AND EXITS
Entrances and exits are visible from behind the bar area yes no n/a
CCTV is installed to monitor blind entrances and exits yes no n/a
Door staff monitor entrances and exits yes no n/a
There is sufficient space for queuing outside the premises yes no n/a
12
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 : On-Licence
Section 101 Sale and Supply of Alcohol Act 2012
This notice must be completed and attached to the On-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 On-Licence in respect to the premises situated at (address):
for the
has made an application to the District Licensing Committee at:
Name
Address
Grant Renewal
Or in respect to a conveyance (e.g. bus, train):
Known as (business name):
The general nature of the business conducted / to be conducted under the licence is (e.g. hotel, tavern, restaurant, nightclub):
The 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
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
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.
Renewal with variation
The following variation(s) to the conditions of licence are sought (if applicable):
13
To be displayed on the premises
Public Notice : On-Licence
Section 101 Sale and Supply of Alcohol Act 2012
This notice must be completed and attached to the On-Licence application so a Licensing Inspector can check
it before it is displayed on the premises.
of an On-Licence in respect to the premises situated at (address):
for the
Grant Renewal
Or in respect to a conveyance (signify type):
Known as (business name):
The general nature of the business conducted / to be conducted under the licence is (e.g. hotel, tavern, restaurant, nightclub):
has made an application to the District Licensing Committee at:
Name
Address
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.
Renewal with variation
The days and hours during which alcohol is / is intended to be sold under the licence are:
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):
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome