Health and wellbeing premises registration form

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

You are

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

Full name

First and last name required.

Residential address

Please include house number, street, suburb and postcode.

Phone

Premises address details

Trading address

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

Phone

This email address will be our primary means of contact with your business.

Proprietor details

Is the proprietor a company?

Yes
No

Business/Company name

Business mailing address

If different from trading address.

First name

Last name

Residential address

Is there another proprietor?

Yes
No

First name of second proprietor

Last name of second proprietor

Residential address of second proprietor

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

Phone number of second proprietor

Email of second proprietor

Trading name

This is the name your business will be known as.

Business mailing address

If different from premises trading address.

Please provide street number, street, suburb and postcode.

Business phone

Mobile number

ABN number

Other information

Primary language used or preferred langage

Health premises details

Type of Health Premises

Type of accommodation

Number of rooms

Number of guests

Number of beds

Proprietor/business owner's date of birth

Open the calendar popup.

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

Plans or photos

Attach plans or photos of your premises

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

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 and the 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.

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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 and present. We Acknowledge all Aboriginal and Torres Strait Islander people who are part of our Greater Geelong community today.

Health and wellbeing premises registration form

Applicant details

Premises address details

Proprietor details

Company details

Name of Proprietor/s