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

Provide the current Health registration number

Date of settlement

Open the calendar popup.

Are you changing the processes in the health business?

Yes
No

Provide details of the changes to the processes

Are you closing to premise to renovate/clean etc?

Yes
No

Reason you are closing the business

Date you plan to commence trading

Open the calendar popup.

You are

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

Your relationship to the business

Agent
Legal representative/solicitor

Full name

First and last name required.

Residential address

Please include house number, street, suburb and postcode.

Phone

Best contact for the business

First name

Last name

Residential address

Email address

Phone number

Premises details

Trading address

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

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

Include the suburb and postcode

Trading name

Shop/premises phone number

Are you renting a space in another business?

Yes
No

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?

Yes
No

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

First trustee name

First trustee address

First trustee phone number

First trustee email address

Is this trustee a company?

Yes
No

Company name

Company ABN

Company mailing address

Company Phone Number

Company Email

Managing director first name

Managing director last name

Managing director address

Managing director phone number

Managing director email

Company details

Is this business part of a company?

Yes
No

Company name

Company ABN

Company mailing address

Company phone number

Company email

Managing director first name

Managing director last name

Managing director address

Managing director phone number

Managing director email

Community group details

Is this business part of a community group?

Yes
No

Community group name

Group mailing address

Community group phone number

Community group email

Group contact person first name

Group contact person last name

Group contact person address

Group contact person phone number

Group contact person email

Individual or partnership

Is this business run by an individual or partnerhsip?

Yes
No

Proprietor first name

Proprietor last name

Proprietor address

Proprietor phone number

Proprietor email

Health premises details

Type of Health Premises

Type of accommodation

Please advise other type of accommodation

Number of rooms

Number of guests

Number of beds

Do you have an agent managing your rooming house?

Yes
No

Agent's first and last name

Agent's address

Please provide house number, street name, suburb and postcode.

Agent's phone

Agent's email

Will you be providing food at this accommodation?

Yes
No

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?

Yes
No

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

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

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

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.

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

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.

Translate

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Aboriginal and Torres Strait Islander flags

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

Health and wellbeing premises registration application

Introduction

STOP FILLING IN THIS FORM