Application for Special Licence
(Section 138, Sale and Supply of Alcohol Act 2012)
General information:
An application for a special licence MUST be lodged at least 20 working days before the event(s)
is to be held.
For large events, we expect applications to be lodged at least 30 working days before the event(s).
Please read the notes over the page carefully and ensure all parts of the application are completed.
Application Checklist:
Supporting documents you need to provide with your application:
Application fee
This is an application fee and is non-refundable after the application is received by
Matamata Piako District Council (see the last page of this application form for details on fees)
A written statement from the owner of the building/property giving consent to the applicant for
alcohol to be sold or supplied on the premises (Note that the written consent must be for the
same party as detailed in the applicant section of this form)
Detailed A4 scale (with measurements) site plan of the premises/site showing:
those areas that are to be used for the sale or supply of alcohol
those areas (if any) that are to be designated as restricted or supervised areas
the principal entrance
location of all food outlets and other relevant activities
A complete list of food and non/low alcoholic beverages provided (menu)
Copies of each manager's certificate for those managing the event (if applicable)
Proof establishing the event(s) as genuine, special or particular occasion(s). Such as a
program of activities / copy of ticket for public events / invitation for private events / promotional
material etc
If this is a large event (400 or more people):
An alcohol management plan
If you are applying for the special licence on behalf of someone else, you must also provide:
A copy of the authority to act as an agent of the applicant, signed by the applicant
Send the completed application form and attachments to:
Liquor Licensing Department
Matamata-Piako District Council
PO Box 266
Te Aroha, 3342
2
Application for Special Licence
(Section 138, Sale and Supply of Alcohol Act 2012)
To the Secretary
District Licensing Committee, Matamata Piako District Council
Application for a special licence is made in accordance with the details set out below.
Applicant details
Full legal name to appear on licence:
(the licensee, i.e. the person or organisation that the proceeds from alcohol sales are going to):
Date of birth (if the applicant is an individual):
Occupation (if the applicant is an individual):
Status of applicant:
Individual person
Trustee
Licensing trust or community trust
Club
Other
(advise what authority under which incorporated)
Partnership
Private company
Public company
Local authority
Postal address (for service of documents):
______________________________________________ Postcode:
Home phone:___________________________ Work phone:
Mobile phone:
E-mail address:
Daytime contact details (if different from above)
Name:
Phone number: _________________________ Mobile number:
E-mail address:
3
Does the applicant (or any company directors) have any criminal convictions?
(other than convictions for offences against provisions of the Land Transport Act 1998 not contained
in Part 6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies)
Yes No
If YES, please state the nature of the offence, date of conviction and penalty suffered:
Nature of the offence
Date of conviction
Penalty suffered
What relevant experience and training does the applicant have relevant to alcohol service
and compliance?
Premises details
Address of premises where event(s) is to be held:
Trading name of premises or name of building:
Does the premises already hold a licence?
Yes No
If YES, state the licence number:
Is a licence sought conditional upon construction or completion of the premises?
Yes No
4
Does the applicant own the proposed licensed premises?
Yes No
If NO - What is the full name and address of the owner?
What form of tenure and term of tenure will the applicant have?
What part (if any) of the premises does the applicant intend should be designated as
(select at least one):
A restricted area (no one under 18 years of age allowed on site)?
A supervised area (minors allowed only with parent or legal guardian)?
Undesignated (any age allowed)?
Event details
Will alcohol sold at the event(s) be for consumption on site or off site?
On site Off site Both
State the nature of the event(s) or occasion(s):
NB If the event is a fundraiser please clarify what/whom the funds are going towards.
5
Will tickets be sold for this event(s)?
Yes No
On which day(s) and during what hours is alcohol to be sold under the licence?
Number of people attending (estimate, if not known):
Probable age distribution of people attending:
Does the applicant intend to engage in the sale or supply of any 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, what is the nature of those other goods and services?
What types of container will alcohol be sold in?
e.g. plastic glasses, paper cups, standard bar glasses, cans, bottles etc.
What is the range (types) of alcohol products you intend to sell and the alcohol percentage (%)?
e.g. Lion Red stubbies 4%, Woodstock 5%, etc.
For off-site applications onlyIf providing tastings, please specify what products, alcohol
percentage (%), and the size of each tasting (ml).
For large events only, what security will you be providing and evidence of their qualifications?
6
Managers (or persons responsible) details
The Sale and Supply of Alcohol Act 2012 requires the appointment of managers for special licences
unless exempted by the District Licensing Committee (DLC). Therefore, for large events and many
medium events certificated manager(s) are essential. For other events the DLC may consider a
‘’responsible person.’’
For each manager or responsible person, please state the full legal name, date of birth and residential
address. If they are certificated managers, please supply a copy of their manager’s certificate(s).
Name
Address
Date of birth
Manager’s certificate
number (if applicable)
Conditions for on-site applications only
What provision will be made for the sale and supply of:
Food?
LOW alcohol beverages (2.5% or less) and NON-alcoholic beverages?
What steps will be taken to provide assistance with or information about alternative forms of transport
from the premises?
7
Conditions for on - AND off-site applications
To what extent, and where, is drinking water to be freely available to patrons?
What steps will be taken to ensure that the requirements of the Act in relation to the sale and supply of
alcohol to prohibited persons are observed?
What steps will be taken to promote the responsible consumption of alcohol?
What other systems (including training systems) and staff will be in place for compliance with the Act?
8
Declaration
The New Zealand police are required by the Sale and Supply of Alcohol Act 2012 to make inquiries
into the suitability of the applicant. This will involve informing the District Licensing Committee and the
Alcohol Regulatory and Licensing Authority of any convictions or concerns involving the applicant.
Should there be any concerns, the applicant will also be informed.
I consent to the release of this information
I hereby state that the above particulars are true and correct
I understand that my application will not be lodged with Council until the application fee is paid
and all required documents are supplied. Incomplete applications will be returned.
Applicant name: Designation:
Signature: ___________________ ____ Date:
Contact us:
Phone: (07) 838 6633
E-mail: customerservices@mpdc.govt.nz
Website: www.mpdc.govt.nz/our-services/alcohol-licensing
Location: 35 Kenrick Street, Te Aroha
9
Alcohol Licensing Fees
Special Licence
There are three fee rates for special licences. The fee depends on the size and number of events
covered by the licence. The new fee system, set by the Ministry of Justice, more fairly reflects the cost
of alcohol licensing.
Use the chart below to determine which category your special licence fits into. All application fees
below are GST inclusive.
Licence Type
Application Fee
Class 3
$63.25
size'
Class 2
$207.00
size', or 1 to 3 events that are of a 'medium size'
Class 1
$575.00
are of a 'large size', 13 or more events that are of ‘small
size’, or 4 or more events that are of ‘medium size’.
A small event is an event that will be attended by less than 100 people.
A medium event is an event that will be attended by between 100-400 people.
A large event is an event that will be attended by more than 400 people.
Please note that it is Matamata Piako District Council that determines the final application fee so you
may be charged further fees before your licence is granted.
Application fees are set by the Ministry of Justice. For more information, see
http://www.justice.govt.nz
.
If you need assistance calculating your application fee, please contact us on the details below.
Contact us:
Phone: (07) 884 0060
E-mail: customerservices@mpdc.govt.nz
Website: www.mpdc.govt.nz/our-services/alcohol-licensing
Location: 35 Kenrick Street, Te Aroha
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