Phone: Mobile: Email: ABN/ ACN (if applicable) INDIVIDUAL 2 Mr Mrs Miss Ms Last/Family name First/Given name(s) Address of Individual 2 making this application: Contact details of Individual 2 making this application: Phone: Mobile: ( ) Email: ABN/ACN (if applicable) COMPANY/INCORPORATED ASSOCIATION DETAILS B. Is a Company/Incorporated Association applying to be the operator of the Food Business? Tick ONE A trading name or trust is not a legal entity and cannot hold a food licence. No Go to Section 2, A Yes Provide details below and complete attachment 1 Name of Company/Incorporated Association Registered Office Address of Company/Incorporated Association This is the address where you can receive legal documents. This may be the same address as the location of the activity. A PO BOX cannot be a registered office address Postal details of Company/Incorporated Association (if different from above) [ Contact details of Company/Incorporated Association Business phone no: ( ) Business fax no: ( ) Business mobile no: Business email address: ABN/ACN (if applicable) APPLICANT SUITABILITY Note: Where this application is in the name of a company, these questions apply to all the executive officers of the Company. Where the application is made by individual(s) these questions also apply. Attach a separate document detailing responses if further space is required. Have you been convicted of an offence under any food legislation? Tick ONE. If yes provide details. No Yes Have you been issued with one or more penalty infringement notices under the Food Act 2006? Tick ONE. If yes provide details. No
Yes Have you ever had a licence under the Food Act 2006, the Food Act 1981 or a corresponding law that was suspended or cancelled? Tick ONE. If yes provide details about the licence, when it was cancelled or suspended and the reasons why. No Yes Have you been convicted of any offence under food legislation in another state or country? Tick ONE. If yes provide details. No Yes Have you owned or operated a business with activities similar to that for which you are making this application? Tick ONE. If yes include details about size, location and nature of the operation. No Yes (Provide details) Do any of your previous roles, responsibilities and education provide you with knowledge that may be relevant to your application? Tick ONE If yes provide details. No PREMISES SUITABILITY Fixed/mobile premises Premises suitability will be considered during this application as part of the assessment. Temporary premises Plans of the site layout will be required to be submitted Have you attached plans of the temporary premises? No Yes (please attach to this application). FOOD SAFETY SUPERVISOR (FSS) Do you have a FSS to nominate for this Food Business? Tick ONE. No (The FSS is unknown at this time). Note: This will not affect the decision made on your application. However you are required to provide the details of your food safety supervisor(s) within thirty (30) days of your licence taking effect. Yes (Please provide details below). Note: If you have additional Food Safety Supervisor(s) to add please attached the details to the application form. Mr Mrs Miss Ms Last/Family name First/Given name(s) Address of FSS Contact details of FSS Phone: Mobile: Email: FOOD BUSINESS DETAILS What is the trading name of the food business? What is the primary location where the food business will be carried out? If more than one location, provide details as an attachment. NOTE: For mobile premises, you need to provide an address where the mobile premises can be inspected within Toowoomba Regional Council Area. For temporary premises, you need to provide details of any proposed locations of the premises to be used for this purpose. For example: Queens Park or for multiple locations: Queens Park, Laurel Bank Park, XYZ markets etc.
Street Number Street Name Suburb/Town Postcode Lot/Plan(s) (if known) Phone no. Mobile no. Email address. Preferred Contact Person Which of the following categories of Food Businesses apply to this application? Child Care Centre Processing food for delivery to vulnerable persons Food Manufacturer Sale of meals at least 12 times each financial year by non-profit organisation Off-Site Caterer On-Site Caterer Private Hospital Sale of unpackaged food by retail - Please specify ______________________ NOTE: Off-site catering, on-site catering and food provided to vulnerable persons (child care centres, aged care facilities and food providers and delivery meal organisations) require a Food Safety Program. Provide details regarding the nature of the catering operation. NOTE: Also attach details of all mobile food vehicles involved in the catering operation. What is the nature of the food business? For example: Washing, preparation, packaging and distribution of ready to eat salads. Preparation, cooking to order and table service of Thai style cuisine. Home business producing and bottling of jams and chutneys for commercial sale. Delivering potable water for human consumption. What is the intended commencement date to start trade? / / What are the expected hours of operation? SECTION 3 – DECLARATION Note: Providing false or misleading information in this application may lead to legal action or prosecution. I declare that: I am the applicant or an authorised signatory for the applicant. The information provided is true and correct to the best of my knowledge. I understand that it is offence under Section 268 of the Food Act 2006 to provide Toowoomba Regional Council (TRC) or an authorised person, documentation containing information that I know is false, misleading or incomplete. I understand that all information provided with this application form may result in the application being refused. I understand that all information supplied on or with this application form may be disclosed publicly in