Application to Renew Registration of a Food Business

DEPARTMENT OF HEALTH

APPLICATION TO RENEW REGISTRATION OF A FOOD BUSINESS

Food Act

Please ensure that this form is returned at least one month prior to expiry of existing registration.

Part 1.  Proprietor’s Contact Details

Title: First Name: Surname:

Company Name: ABN/ACN:

Postal Address:

Suburb: State: Postcode:

Telephone: Mobile:

Email:

Part 2.  Premises Location Details

Trading Name:

Site Manager’s Name: (The best contact person for general business enquiries)

Title: First Name: Surname:

Premises Address:

Suburb: State: Postcode:

Telephone: Mobile:

Email:

Trading Name:

Site Manager’s Name: (The best contact person for general business enquiries)

Title: First Name: Surname:

Premises Address:

Suburb: State: Postcode:

Telephone: Mobile:

Email:

Trading Name:

Site Manager’s Name: (The best contact person for general business enquiries)

Title: First Name: Surname:

Premises Address:

Suburb: State: Postcode:

Telephone: Mobile:

Email:

Preferred method of contact: ⃝ Post ⃝ Email (preferred)

Note: If your business operates from more than three locations, please attach a separate sheet of paper with their details as outlined above.

Part 3.  Water Supply

If your businesses uses a private water supply e.g. bore water, rainwater etc. you have a responsibility under the Food Act to demonstrate that this is a potable water supply. For more information, please refer to our website or contact Environmental Health.

If applicable, have you attached your microbiological test results? ⃝ YES ⃝ NO

If applicable, have you attached your chemical test results? ⃝ YES ⃝ NO

Part 4.  Description of Business

If the business has undergone any changes since previous registration e.g. name, structure, ownership, processes, menu, trading locations etc., please detail here:

Part 5.  Fees

Fees are expressed as revenue units and are adjusted each financial year in line with increases in the Darwin Consumer Price Index. As of 1 July 2016, revenue units are valued at $1.15. The total fee is rounded down to the nearest dollar, as detailed below. All fees are GST exempt.

Note: please refer to your current risk type. If this application is included with a renewal letter, refer to the top of the letter. If you do not know your risk, or your risk has changed since last registration, you must contact environmental health to determine your risk classification prior to payment of fees.

Select ONE fee payment only:

Type of Business / Revenue Units / Current Fee / ü
Food Business – Class 1 (High Risk) / 180 / $207.00 / ⃝
Food Business – Class 2 (Medium Risk) / 90 / $103.00 / ⃝
Food Business – Class 3 (Low Risk) / 45 / $51.00 / ⃝

Payment and Submission

Fees can be paid over the phone, via post or in person at your nearest Receiver of Territory Monies (RTM) office:

RTM CASUARINA
The Domain
16 Scaturchio St, Casuarina NT 0810
PO Box 40250
Casuarina NT 0811
Phone: (08) 8943 6219
Email: / RTM DARWIN
Level 7, Charles Darwin Centre (CDC)
19 The Mall, Darwin NT 0800
GPO Box 2391
Darwin NT 0801
Phone: (08) 8999 1628
Email: / RTM ALICE SPRINGS
1st Floor, Alice Springs Plaza
36 Todd St, Alice Springs NT 0870
PO Box 4037
Alice Springs NT 0871
Phone: (08) 8951 6491
Email:

If you pay via post or in person, you may submit this application to the RTM, who will then forward it on to the nearest Environmental Health office. If you pay over the phone, you will need to submit this application to the nearest Environmental Health office.

EH TOP END
Floor 2B, Casuarina Plaza, 238 Trower Rd, Casuarina NT 0810
PO Box 40596, Casuarina NT 0811
Phone: (08) 8922 7377
/ EH KATHERINE
1st Floor, O’Keefe House, Katherine Hospital, Katherine NT 0850
PMB 73, Katherine NT 0852
Phone: (08) 8973 9062
/ EH CENTRAL AUSTRALIA
Peter Sitzler Building, 67 Stuart Highway, Alice Springs NT 0870
PO Box 721, Alice Springs NT 0871
Phone: (08) 8955 6122
/ EH BARKLY
Level 1, Matt Glynn Building, 172 Paterson St, Tennant Creek NT 0860
PO Box 346, Tennant Creek NT 0861
Phone: (08) 8962 4302

Part 6.  Declaration

I hereby declare that the information contained in this application is accurate and correct to the best of my knowledge.

Name: Signature: Date:

Note: All businesses must notify Environmental Health of any changes in ownership, nature of food handling or structure/fit-out.

Note: No signature is required if submitting the form electronically. Electronic submission will be considered to be agreeing to the stated declaration.

Food – Renew Page 3 of 3 www.nt.gov.au

Department of Health is a Smoke Free Workplace