Health and wellbeing premises registration application

Please complete and submit to register a premises under the Public Health & Wellbeing Act.

If you planning to buy or take over an existing Public Health and Wellbeing Act registration you will need to request a transfer form.

Introduction

You are

Registering a new health business
Relocating a business from another site
Taking over a business that is currently registered

Please provide You are

Provide the current Health registration number

Please provide Provide the current Health registration number

Date of settlement

Open the calendar popup.

Please provide Date of settlement

Are you changing the processes in the health business?

Please provide Are you changing the processes in the health business?

Provide details of the changes to the processes

Please provide Provide details of the changes to the processes

Are you closing to premise to renovate/clean etc?

Please provide Are you closing to premise to renovate/clean etc?

Reason you are closing the business

Please provide Reason you are closing the business

Date you plan to commence trading

Open the calendar popup.

Please provide Date you plan to commence trading

You are

the business owner
completing this application on behalf of the business owner

Please provide You are

Your relationship to the business

Agent
Legal representative/solicitor

Please provide Your relationship to the business

Full name

First and last name required.

Please provide Full name

Residential address

Please include house number, street, suburb and postcode.

Please provide Residential address

Please check the Email addressPlease provide Email

Phone

Please provide Phone

Best contact for the business

First name

Please provide First name

Last name

Please provide Last name

Residential address

Please provide Residential address

Email address

Please check the Email addressPlease provide Email address

Phone number

Please provide Phone number

Premises details

Trading address

Start typing in your street address, then select it from the list.

Please provide Trading addressPlease check the Trading address, be sure to start typing in your street address, then select it from the dropdown list.

If address does not appear in search, type the full address here

Include the suburb and postcode

Trading name

Please provide Trading name

Shop/premises phone number

Please provide Shop/premises phone number

Are you renting a space in another business?

Please provide Are you renting a space in another business?

Name of other business

Please provide Name of other business

Business details

You must select one of the following options. Your business must fall under one of the following:

Trust
Company
Individual Proprietor
Community Group

Trust Details

Is this business part of a trust?

Please provide Is this business part of a trust?

Name of trust

Please provide Name of trust

Upload a copy of the Trust Deed Particulars and signatures page

Select file to upload (doc,docx,pdf). File size limit: 20MB

Please check for acceptable file types and file size is within the limitFilenames cannot contain the following characters *?"<>|Please provide Upload a copy of the Trust Deed Particulars and signatures page

First trustee name

Please provide First trustee name

First trustee address

Please provide First trustee address

First trustee phone number

Please provide First trustee phone number

First trustee email address

Please check the Email addressPlease provide First trustee email address

Is this trustee a company?

Please provide Is this trustee a company?

Upload a copy of the ASIC company extract showing ABN and all directors and their details.

Select file to upload (doc,docx,pdf). File size limit: 20MB

Please check for acceptable file types and file size is within the limitFilenames cannot contain the following characters *?"<>|Please provide Upload a copy of the ASIC company extract showing ABN and all directors and their details.

Company name

Please provide Company name

Company ABN

Please provide Company ABN

Company mailing address

Please provide Company mailing address

Company Phone Number

Please provide Company Phone Number

Company Email

Please check the Email addressPlease provide Company Email

Managing director first name

Please provide Managing director first name

Managing director last name

Please provide Managing director last name

Managing director address

Please provide Managing director address

Managing director phone number

Please provide Managing director phone number

Managing director email

Please check the Email addressPlease provide Managing director email

Company details

Is this business part of a company?

Please provide Is this business part of a company?

Company name

Please provide Company name

Company ABN

Please provide Company ABN

Company mailing address

Please provide Company mailing address

Company phone number

Please provide Company phone number

Company email

Please check the Email addressPlease provide Company email

Managing director first name

Please provide Managing director first name

Managing director last name

Please provide Managing director last name

Managing director address

Please provide Managing director address

Managing director phone number

Please provide Managing director phone number

Managing director email

Please check the Email addressPlease provide Managing director email

Upload a copy of the ASIC company extract showing ABN and all directors and their details.

Select file to upload (doc,docx,pdf). File size limit: 20MB

Community group details

Is this business part of a community group?

Please provide Is this business part of a community group?

Community group name

Please provide Community group name

Group mailing address

Please provide Group mailing address

Community group phone number

Please provide Community group phone number

Community group email

Please check the Email addressPlease provide Community group email

Group contact person first name

Please provide Group contact person first name

Group contact person last name

Please provide Group contact person last name

Group contact person address

Please provide Group contact person address

Group contact person phone number

Please provide Group contact person phone number

Group contact person email

Please check the Email addressPlease provide Group contact person email

Individual or partnership

Is this business run by an individual or partnerhsip?

Please provide Is this business run by an individual or partnerhsip?

Proprietor first name

Please provide Proprietor first name

Proprietor last name

Please provide Proprietor last name

Proprietor address

Please provide Proprietor address

Proprietor phone number

Please provide Proprietor phone number

Proprietor email

Please check the Email addressPlease provide Proprietor email

Health premises details

Type of Health PremisesPlease provide Type of Health Premises

Is the proprietor/operator a registered nurse or other medical practitioner under Australian Health Practitioner Regulation Agency (AHPRA) and doing only skin penetration activities that are covered by this?

Please provide Is the proprietor/operator a registered nurse or other medical practitioner under Australian Health Practitioner Regulation Agency (AHPRA) and doing only skin penetration activities that are covered by this?

Upload your current medical registration

Select file to upload (doc,docx,pdf,jpg,png,gif,xls,xlsx,ppt,pptx,txt,rtx). File size limit: 20MB

Please check for acceptable file types and file size is within the limitFilenames cannot contain the following characters *?"<>|Please provide Upload your current medical registration

You understand that the Environmental Health Officer will discuss any exemption/s under the Public Health and Wellbeing Act and that any exemption will only be valid while your AHPRA registration is current.

I understand

Please provide I understand

Attach plans or photos of your premises

Select one or more files to upload (doc,docx,pdf,jpg,png,gif,xls,xlsx,ppt,pptx,txt,rtx). File size limit: 25MB

Please check for acceptable file types and file size is within the limitFilenames cannot contain the following characters *?"<>|Please provide Attach plans or photos of your premises

If you are taking over a food business that is currently registered, please attach current photos or plans of the food preparation area.

Date you will be starting to trade

Open the calendar popup.

Please provide Date you will be starting to trade

Fees

The fees for your application may vary according to the level of food risk. More information can be found on our fees page.

We will invoice you for any fees related to your business when your application has been assessed.

Payment of this invoice required for your application to proceed.

Statement

You understand that:

the information provided in the application is true and complete, to the best of your knowledge
this application forms a legal document and penalties exist for providing false and misleading information
We, City of Greater Geelong, may refuse this application if it becomes evident that any information or supporting documents provided are incomplete or false
where the commercial activities are located with a predominantly residential land use, we will apply a Mixed Use rate which is lower than the commercial rate but higher than the residential rate; the current rates are available in our Rating Strategy
by ticking this box, you confirm that you are the person named above.

You agree

Please provide You agree

Privacy

This information is collected under the requirements of the Food/Public Health & Wellbeing Act for enforcement of Public Health purposes.

It may be provided to the Department of Health for the same purposes, and for the statistical purposes related to the application of the Act.

It will be treated in compliance with the Department of Health Information Privacy Principles and the Information Privacy Act.

We Acknowledge the Wadawurrung People as the Traditional Owners of the Land, Waterways and Skies. We pay our respects to their Elders, past and present. We Acknowledge all Aboriginal and Torres Strait Islander people who are part of our Greater Geelong community today.

Our council

Our services

What’s happening

Health and wellbeing premises registration application

Introduction

STOP FILLING IN THIS FORM

Applicant details

Best contact for the business

Premises details

Business details

Trust Details

Company details

Community group details

Individual or partnership

Health premises details

Plans or photos

Fees

Statement

Privacy

Our council

Our services

What’s happening

Health and wellbeing premises registration application

Introduction

STOP FILLING IN THIS FORM

Applicant details

Best contact for the business

Premises details

Business details

Trust Details

Company details

Community group details

Individual or partnership

Health premises details

Plans or photos

Fees

Statement

Privacy

Privacy policy