Application To Register A Food Premises

I/We the undersigned, hereby apply to register/renew/transfer under the provisions of the Food Act 1984 the Premises described hereunder and depicted in the floor plan attached lodged with ALPINE RESORTS VICTORIA trading as FALLS CREEK ALPINE RESORT ('FCAR') for the year commencing 1 May 2022.

Proprietor Details

Name Of Applicant: *

Authority (e.g. Director of Company): *

Company Name: *

ABN/ACN: *

Postal Address: *

City:

State/ Province/ Region: *

Postal Code/ Zip Code: *

Country: *

Phone Number: *

Email Address: *

Premises Details

Business or Trading Name: *

Company Name (If applicable):

Address of Premises: *

Contact person at premises (if applicable):

Premises City: *

Premises State/ Province/ Region: *

Premises Postal/ Zip Code: *

Premises Country: *

Premises Phone Number: *

Community Groups

A community group is a non-for-profit organisation or a person(s) undertaking a food handling activity solely to raise funds for charitable purposes or for a non-for-profit organisation.

Are you selling unpackaged ready to eat high risk food?

YesNoOther (Class 4 food premises)

Are you selling high risk food for more than two consecutive days at a time and most food handlers are volunteers?

If YES, you will require a Food and Safety Supervisor:

YesNo

Description Of Use Of Premises

(e.g. Commercial kitchen, restaurant, facility for the preparation of food to be sold from a mobile food vehicle, etc.)

Following discussion with Council about your food handling activities, select your food premises classification below as advised by your Council.

For further information, refer to the Food Classification Tool at:

http//www.foodsmart.vic.gov.au/foodclass/

Number Of Staff:

Primary Language Used:

Is Tobacco Sold:

If so, only from a vending machine?

Does the premises have sit-in dining?

Does the premises have a license to sell liquor?

Food Safety Program

Please indicate if Template or Independent (non-standard):

TemplateIndependent (non standard)

PLEASE THIS SECTION IF YOU ARE REQUIRED TO HAVE A FOOD AND SAFETY PROGRAM (SEE OVERLEAF)

1. Food safety program template for class 2 retail & food service:

Yes No

Name of Program

2. Food Smart (online)

Yes No

Date of Last Audit (or proposed audit date): *

3. Other FSP template registered by the Secretary of Department of Health: *

YesNo

Name of Program:

Registered number of Template:

Auditor Name:

Registration No:

Required Food Safety Program Documents

There are no attachments if you have a template standard food safety program.

Class 1 premises – copy of the non-standard/ independent food safety program (1 copy)

Class 1 premises – A current certificate from an approved food safety auditor indicating that the FSP is adequate only if applicable (1 copy)

Class 2 premises – A current certificate from an approved food safety auditor stating that the FSP meets the requirements of the Act only if applicable (1 copy)

Class 2 premises – if you have not attached the current certificate from an approved auditor – attach a copy of the non-standard/ independent food safety program (1 copy)

Attachments

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Attachments

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Food Safety Supervisor

Food Safety Supervisor (Class 1, Class 2 and Class 3A)

Name:

Phone Number of Applicant:

Email:

Please attach a copy of evidence of required qualifications for the nominated Food Safety Supervisor

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DECLARATION

Class 1, 2, 3 and 3A food premises I understand and acknowledge that: The information provided in this application is true and complete to the best of my knowledge This application is a legal document and penalties apply for providing false and misleading information In addition to the above and by ticking this box, I acknowledge that I will ensure that the appropriate minimum records required under the Food Act 1984 for the premises will be kept. If the business is owned by a sole trader or as a 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. *

I Agree

Sign

PRIVACY STATEMENT:

This information is collected under the requirements of the Food Act for enforcement and Public Health purposes. It may be provided to the Department of Human Services for the same purposes, and for statistical purposes related to the application of the Act. It will be treated in compliance with the Department of Human Services Information Privacy Principles and the Information Privacy Act.

Full Name: *

Date: *

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