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:______

Food – Renew Page 1 of 3 www.nt.gov.au Department of Health is a Smoke Free Workplace DEPARTMENT OF HEALTH 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.

Food – Renew Page 2 of 3 www.nt.gov.au Department of Health is a Smoke Free Workplace DEPARTMENT OF HEALTH Select ONE fee payment only: Type of Business Revenue Units Current Fee  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 RTM DARWIN RTM ALICE SPRINGS The Domain Level 7, Charles Darwin Centre (CDC) 1st Floor, Alice Springs Plaza 16 Scaturchio St, Casuarina NT 0810 19 The Mall, Darwin NT 0800 36 Todd St, Alice Springs NT 0870 PO Box 40250 GPO Box 2391 PO Box 4037 Casuarina NT 0811 Darwin NT 0801 Alice Springs NT 0871 Phone: (08) 8943 6219 Phone: (08) 8999 1628 Phone: (08) 8951 6491 Email: [email protected] Email: [email protected] Email: [email protected] 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 EH KATHERINE EH CENTRAL AUSTRALIA EH BARKLY Floor 2B, Casuarina Plaza, 238 1st Floor, O’Keefe House, Peter Sitzler Building, 67 Level 1, Matt Glynn Building, Trower Rd, Casuarina NT Katherine Hospital, Katherine Stuart Highway, Alice Springs 172 Paterson St, Tennant 0810 NT 0850 NT 0870 Creek NT 0860 PO Box 40596, Casuarina NT PMB 73, Katherine NT 0852 PO Box 721, Alice Springs NT PO Box 346, Tennant Creek 0811 Phone: (08) 8973 9062 0871 NT 0861 Phone: (08) 8922 7377 [email protected] Phone: (08) 8955 6122 Phone: (08) 8962 4302 [email protected] [email protected] [email protected]

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