Checklist
Special licence (On-site or Off-site)
Sale and Supply of Alcohol Act 2012
The following must be included in your application or it will be returned
Fees
Fees include GST and are non-refundable. If it is determined that the class fee category should be changed, any additional fee
must be paid before the licence is issued.
Small event: Fewer than 100 people attending
Medium event: Between 100 and 400 people attending
Large event: More than 400 people attending
Special Licence Class Class description Fee
Class 1 1 large event; 4 or more medium events; 13 or more small events $575
Class 2 3 to 12 small events; 1 to 3 medium events $207
Class 3 1 or 2 small events $63.25
Please tick when completed:
Completed application
Prescribed fee paid (non-refundable)
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)
A copy of the invitation, ticket and any promotional material
Completed Building Owner’s Approval/Building Evacuation Declaration (attached)
Copies of any Managers’ Certificates
A4 or A3 to scale plan of the premises, clearly labeled, showing all of the following (if required):
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 full layout of the event (location of the bar, food, water, stage, etc.)
Map showing location of premises, or a route map for conveyances (if required)
Copy of Certificate of Incorporation (if applicable)
An alcohol management plan (required for large events)
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.
A building consent may be required for marquees or tents, or if you intend to use a building not normally used as a licensed
premises. Contact the Council’s building department.
A resource consent may be required if the proposed activity is not allowed under the Wairarapa Combined District Plan.
Contact the Council’s planning department.
O
ffice Use Only
Class: Fee: Payment received:
/ /
Allow as much time as possible to obtain the consents you need. Unopposed special licence
applications take 20 working days to process; 40 working days for large events. Applications received
outside these timeframes might not be processed in time for the event.
Application
Special licence (On-site or Off-site)
Sale and Supply of Alcohol Act 2012
1 Application Details
c) Late applications: State the reason why you are applying less than 20 working days before the event/first event, and if the
even
t could have been reasonably foreseen
.
b) Status of Applicant:
a)
Full legal name(s) to be on licence:
2 Applicant Details
To: The Secretary
District Licensing Committee
(Please tick one)
Carterton
Masterton
South Wairarapa
a) Application type:
On site (alcohol will be consumed on the premises/at the event)
Off site (alcohol will be consumed somewhere else, e.g. takeaways)
NCS No.
Private Company
Partnership
Registered Limited Partnership
Body Corporate
Trustee
Territorial Authority
Incorporated Society/Charitable Trust
Club
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)
c) Postal address for service of documents:
d) Have you or your organisation previously held a Special Licence?
Yes No
Note, only manufacturers, distributors, importers or alcohol wholesalers can apply for an off site licence)
b) Is there an existing licence for the premises or conveyance?
Yes
- Licence type:
Licence number:
No
On-Licence Club Licence
Off-Licence
2
e) Business details (describe the principal business; any other businesses):
4 Premises or Conveyance Details
3 Manager/Supervisor Details
Full Name Certificate Number Expiry Date Driver’s licence number
(if no certificate)
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
PREMISES ONLY:
d) Applicant Details:
Name
Email
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:
Date of Birth
Occupation
Telephone
Mobile
Mail Email
If no attach a completed building owner’s approval form (page 6 of this form)
e) Type (car, bus, etc.)
f) Trading name for conveyance
g) Home base address (if any)
CONVEYANCE ONLY:
3
Describe the event in detail and attach a separate sheet if necessary:
a) What is the general nature of the event?
b) The days and hours proposed for the sale of alcohol:
5 Event Details
c) Estimated number of people attending:
d) Probable age distribution of people attending:
e) Entry arrangements (tickets, invitation, door sales, members, etc.):
f) Principal purpose of the event (fundraiser, prize-giving, birthday):
g) How will alcohol be sold:
Cash bar Other (please describe):
Yes No
h) Do you intend to sell or supply goods other than alcohol and food, or provide any services not directly related to the sale
and supply of alcohol and food?
If yes, please describe:
k) Will you do sample alcohol tastings?
(note: tastings are defined as 40ml or less)
Glass - size ____________
Cans - size _____________
Paper/plastic - size ____________
i) Parts (if any) of the premises intended to be designated as a:
Restricted area (no under-18s):
Supervised area (under-18s with a legal guardian):
j) What type of container will alcohol be sold in:
Yes No
l) On-site Special Licence only - Please attach a menu or list of food and beverages, including descriptions and prices.
4
a) Describe to what extent and where drinking water will be freely available to patrons:
c) Describe the steps that will be taken to prevent the sale and supply of alcohol to minors and intoxicated people:
b) If there is no access to mains water supply, please comment on the potability of the water that will be available:
d) Describe what steps will be taken and what information will be provided to help with transport options from the licensed
premises (e.g. taxis, shuttles, etc.):
6 Conditions
f) Describe any other systems (including training and security) and staff that are, or will be, in place to comply with the Act:
e) Describe what experience and training that applicant has in relation to the sale and supply of alcohol:
g) Describe any steps that will be taken to promote the responsible consumption of alcohol:
5
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. If required by the secretary of the District Licensing Committee, the applicant must ensure that notice of this application (in Form 8) 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.
Da
ted this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________
Special Licence
6
______________________________________
Owner’s Signature
______________________________________
Owner’s Name (print)
I have no objection to (name of applicant):
Using my premises situated at:
Special Licence
Owner’s Approval
For the purpose of:
To take place on (date):
I hereby state that as 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 an evacuation procedure that meets
the requirements of the Fire and Emergency New Zealand Act 2017.
______________________________________
Date
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 website 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.
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