Application Form W-1: Registration of Wine Standards Management Plan

Application for registration under the Food Act 2014 with Tauranga City Council

Before you start, let’s check that you have everything you will need: The completed Scope of Operations document. Find this at http://www.tauranga.govt.nz/services/alcohol-food-health/food- health/food-business.aspx If you are applying for a National Programme (NP) registration, you need to choose a private verifier. You will also need a confirming letter from your verifier to attach to this application. A list of recognised verification (or audit) agencies can be found on the MPI website, under ‘registers and lists’. If you are having trouble finding a local verifier, contact a Tauranga City Council Environmental Health Officer on Phone: 07 577-7000. The law requires Councils to verify businesses registered under the template Food Control Plan. If any of the business covered in this application are registered limited liability company, a copy of the company registration certificate. See www.companies.govt.nz. Registration information for every address covered in this application. Attaching a spreadsheet to the application is preferred. You need to make sure you can confirm that the operator of the food businesses is resident in New Zealand within the meaning of section YD 1 or YD (excluding section YD 2(2)) of the Income Tax Act 2007. A site plan for each premises covered in the application showing the layout of the place you operate your business, the physical boundaries and the types of activity carried out on neighbouring properties. Registration Fee to Pay $280.00, (plus $420.00 Verification fee for Template Food Control Plans only).

What type of registration are you applying for? Template Food Control Plan National Programme Level 1 National Programme Level 2 National Programme Level 3 Hint: To find out which type of registration fits your business use the “Where Do I Fit” tool found on the Ministry of Primary Industries website https://www.mpi.govt.nz/food-safety/food-act-2014/where-do-i-fit/

If you were registered before 1 March 2016, what were you registered under? Food Hygiene Regulations 1974 Food Control Plan under the Voluntary Implementation Programme Not Applicable Other ………………………………………………………………………………………………………

Applicant Details:

Legal Name(s) of Applicant (e.g. Registered Company Name, Partnership or Individual): ……………………………………………………….

……………………………………………………………………………………………………………………………………………………………………………………….…… I have attached a copy of the company name registration from the New Zealand companies’ office

Physical Address………………………………………………………………………………………………………………………………………………………………….….

……………………………………………………………………………………………………………………………………………………………………………………….…… This address is a private dwelling house and I wish it to be withheld from the public registrar.

Postal Address………………………………………………………………………………………………………………………………………………………………….….

……………………………………………………………………………………………………………………………………………………………………………………….…… This address is a private dwelling house and I wish it to be withheld from the public registrar.

Fees must be paid with application:

(for office use)Annual – Lodgment Code: PREG

of 4 Fee Paid………………………………... Application No...... ………………...…... Premise No………………...... ……...

Receipt No...... Approved/Declined by...... Database Updated……………….….

Date Receipted Contact Id………………………………. Reference Plan: DECEMBER 2015

Phone: Mobile…………………………………………. Work…………………...…...……………. Home………………...…………………………….

Email……………………………………………………………...…………………………………………………….…………….

Premises Name (Trading Name) …………......

Premises Physical Address: …………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………….…… This address is a private dwelling house and I wish it to be withheld from the public registrar

Day to Day Manager of the Template Food Control Plan or National Programme:

Name: ………………………………………………………...………………………………………………

Position: ……………………………………………………………...………………………………………………

Phone: Mobile…………………………………………. Work…………………...…...……………. Home………………...…………………………….

Email……………………………………………………………...…………………………………………………….…………….

Who will be doing your verification?

Council (all Template Food Control Plans):

Other (all National Programmes) insert agency name……………………………………………………………….….………………….……………. (I have attached a confirming letter from my verification agency)

Details for additional premises included in Template Food Control Plan:(if necessary attach a fie (e.g. spreadsheet) Company registration certificate Vehicle Legal name(s) of site operator is attached Registration (e.g. registered company, for any numbers partnership or individual) limited (mobile (This is for Template Food liability Premises Physical businesses Site day-to-day Control Plan registrations only). companies) Premises trading name: Address only) manager position E.g. ABC Foods Limited E.g. Yummy Cakes E.g. 123 The Strand, E.g. Store Tauranga Store Tauranga Manager

of 4 Applicant Statement:

I CONFIRM THAT: 1. I am authorised to make this application as the operator or a person with legal authority to act on behalf of the operator; and 2. The information supplied in this application is truthful and accurate to the best of my knowledge and belief; and 3. I am authorised to make this application on behalf of all additional premises listed that will be covered by Food Control Plan, and 4. Every operator of the food businesses covered by the Food Control Plan is resident in New Zealand within the meaning of section YD 1 or YD 2 (excluding section YD 2(2)) of the Income Tax Act 2007; and 5. Every operator of the food businesses covered by the Food Control Plan is able to comply with the requirements of the Food Act 2014.

Name..………………………………………………………………….…………………………………………. Job title.……………………………………………………………….

Signed..………………………………………………………………….…………………………………………. Date..…………………………..………………………………………. Registration Fee to Pay:

Template Food Control Plan registration (food FCP) $280.00 plus verification $420.00. – Total to pay $700.00 Note:  Includes one copy of the Template Food Control Plan. Additional plans for extra sites available at a cost of $50.00 per plan. Alternatively, Template Food Control Plans are free to download from the Ministry of Primary Industries website.

 Verification fee of $420.00 includes 3 hours of staff time. Additional time will be charged at $140.00 per hour.

National Programme registration (food NP) $280.00

All Fees must be paid with application:

PAYMENTS MAY BE MADE: Electronically to: ANZ Tauranga Account Number: 06 0433 0213474 00 Reference: Food FCP or Food NP Code: Applicant Name: In Person: At Tauranga City Council, 91 Willow Street, Tauranga Or posted to: Tauranga City Council, Private Bag 12022, Tauranga 3143 Final check before sending your application to Tauranga City Council:

HAVE YOU: filled this form in completely, and legibly and read and signed the Applicant Statement attached the completed Scope of Operation document attached site plan attached a letter from your verifier if that isn’t Tauranga City Council attached copies of company registration certificates if you have a registered limited liability company? included payment for this application

Collection of information: Collection of Personal Information Pursuant to Principle 3 of the Privacy Act 1993, we advise that:

This information is being collected for the purpose of registering under the Food Act 2014; and

The recipient of this information, which is the agency that will collect and hold the information, is MPI, PO Box 2526, Wellington 6140; and Page 3 of 4 Some of the information collected will be displayed on a public register; and

The collection of information is authorised under section 53 or section 83 of the Food Act 2014, which ever applies. The provision of this information is necessary in order to process an application for registration under either section 53 or section 83; and

The supply of this information is voluntary; and

Failure to provide the requested information is likely to result in a return of this application form to the applicant, and may ultimately result in a refusal to register, in accordance with section 54 and 57 or section 84 and 87, of the Food Act 2014, which ever applies; and

Under Principles 6 and 7 of the Privacy Act 1993, you have the right of access to, and correction of, any personal information that you have provided.

Collection of Official Information

All information provided to the Ministry for Primary Industries is official information and may be subject to a request made under the Official Information Act 1982.

If a request is made under that Act for information you have provided in this application, the Ministry for Primary Industries must consider any such request in accordance with its obligations under the Official Information Act 1982 and any other applicable