Notification of a Food Premises
Class 4 Food Premises Information
The Food Act 1984 (the Act) regulates the sale of food for human consumption. This form is only Applicable to
Class 4 food premises. If you do any other food handling activities that are not described below, contact Council as
this may alter your food premises classification.
For a full list of food activities go to: http://www.health.vic.gov./foodsafety. If your activities fall into Class 1, 2 or 3
you will be required to complete the Application to Register a Food Premises form and pay the relevant fees. Do
not complete this form.
This form is to be used for fixed premises only. If you are conducting any of the activities below from a temporary
food premises (ie. market stall, mobile food premises, cart) you will need to lodge your Notification via StreaTrader.
Please visit https://streatrader.health.vic.gov.au.
Business Details
Trading Name:
Street Address:
Suburb:
State:
Postcode:
Premises Type:
(ie, newsagency, milkbar, childcare etc)
Food Handling Activity
You will be a Class 4 premises and will need to lodge this NOTIFICATION if your only food handling activities are:
Please tick () one or more of the following food activities:
Alcohol:
The sale of packaged alcohol. (ie bottle shops.)
Low Risk Foods:
The sale of shelf stable pre-packaged low risk food such as
confectionery, chips, frozen ice-cream, milk, bottled drinks.
( ie. newsagents, pharmacies, video stores and some milk bars.)
Packaged Cakes:
The sale of packaged cakes (excluding cream).
Uncut Fruit & Vegetables:
The sale of uncut fruit and vegetables. (ie. farm gate sales,
greengrocers and wholesalers.)
Wine Tastings:
Wine tasting for members of the public, which may include the
serving of hard cheese or low risk food that has been prepared and
is ready to eat.
Sessional
Kindergarten/Childcare:
Supplying low risk food, including cut fruit.
Tobacco Retail Activity
Please tick () this box if you also sell tobacco products from the same premises.
Tobacco
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As At: December 2014
Notification of a Food Premises
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Proprietor Details
Company (please complete the details for No. 1 only).
Individual or Partnership (please complete the details for No. 2 only).
1.
Company
Please attach a copy of your Australian Securities & Investment Commission (ASIC) Extract to this
application to verify the details below.
Company Name:
ACN:
Do not provide PO Box details in this section. If you want to use a different address to this one for
correspondence please ALSO complete Postal Address details on Page 3.
Registered
Office Address:
Suburb:
State:
Phone:
Postcode:
Mobile:
Email:
Communication:
Email only
Post only
Proceed to 3. Primary Contact.
2.
Individual/Partnership(s)
Proprietor (1)
Please use Proprietor 1 as the Primary Contact; OR
I will nominate another person at (3. Primary Contact) for my business.
Title:
First Name:
Surname:
Do not provide PO Box details in this section. If you want to use a different address to this one for
correspondence please ALSO complete Postal Address details on Page 3.
Street Address:
Suburb:
State:
Phone:
Postcode:
Mobile:
Email:
Communication:
Email only
Post only
Proprietor (2)
Title:
First Name:
Surname:
Do not provide PO Box details in this section. If you want to use a different address to this one for
correspondence please ALSO complete Postal Address details on Page 3.
Street Address:
Suburb:
Phone:
Postcode:
Mobile:
Email:
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As At: December 2014
Notification of a Food Premises
Page 3 of 4
If there are more than 2 Proprietors for this business please attach their details to this application.
3.
Primary Contact
Complete the details below if the proprietor is a Company, or if the Primary Contact details are different to
the details of the proprietors.
Title:
First Name:
Surname:
Relationship to
Business:
Phone:
Mobile:
Email:
4.
Postal Address
Please use the Proprietor details for correspondence.
I will nominate another address below to receive correspondence.
Postal Address:
Suburb:
State:
Postcode:
Declaration
I understand and acknowledge that:
-
The information provided in this application is true and complete to the best of my knowledge.
This application forms a legal document and penalties exist for providing false or misleading information.
I am over 18 years at the time of completing this application.
If the business is owned by a sole trader or partnership, the proprietor(s) must sign and print name(s).
If the business is owned by a company or association, the applicant on behalf of that body must sign and print their
name.
By ticking () this checkbox I confirm that I have read and understood all of the statements above.
Name:
Signature:
Date:
Name:
Signature:
Date:
Privacy Statement
The information gathered in the form is used by Council to process the application. To view Council's privacy policy,
please either visit Council's offices or go to Council Privacy statement located at: www.yarraranges.vic.gov.au.
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As At: December 2014
Notification of a Food Premises
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Lodgement
This application can be lodged at any of our community links, by post or via fax or email:
Postal Address:
Yarra Ranges Council
Public Health Services
PO Box 105
LILYDALE VIC 3140
Community Link Locations:
HEALESVILLE
LILYDALE
MONBULK
UPWEY
YARRA JUNCTION
110 River Street, Healesville
Civic Centre, 15 Anderson St, Lilydale
21 Main Rd, Monbulk
40 Main St, Upwey
2442-2444 Warburton Highway, Yarra Junction
Ph: 5965 3501
Ph: 1300 368 333
Ph: 9756 7677
Ph: 9752 6054
Ph: 5967 2875
Opening Hours:
Monday – Friday
Saturday
Public Holidays
9.00am – 5.00pm (Lilydale from 8.30am)
9.00am – Noon
Closed
Contact Details
Version 2
Telephone:
1300 368 333
Fax:
03 9735 4249
Email:
mail@yarraranges.vic.gov.au
Website:
www.yarraranges.vic.gov.au
As At: December 2014