Food Business Registration Form Section 1: Food Business Details Contact Name: Trading Name of Business: Address of Business: Business Size: (Full time equivalents) 1-10 employees 11 or more employees PRIMARY Business Type: (tick one) Aged Care Facility Bakery Bed & Breakfast Canteen/Kitchen Caterer Childcare Centre Fruit & Veg Retailer Health Food Shop Home Occupation Hotel/Motel Licensed Club Pub/Tavern Restaurant/Cafe School/Education Facility Service Station Sporting Complex Supermarket Take Away Food Winery Mobile Van (inc make, model & registration details) Other Type of Food Business: Business Ownership: Individual Company Partnership Other Name of Individual: Name of Company: Partnership Details: ABN Number: Registered Office Address: Phone Business Hours: Email: Postal Address: Suburb: State: Postcode: Section 3: Food Safety Supervisor (FSS) Details Certain hospitality and retail food service sector businesses must also designate a FSS. If an FSS is required, a copy of the Certificate must be available upon request of Council's Environmental Health Officers. Each food premises must maintain a copy of the current FSS on the premises at all times. Name of Supervisor: Expiry Date: The information on this form is being collected to allow Council to process your application and/or carry out its statutory obligations. All information collected will be held by Council and will only be used for the purpose for which it was collected. An individual may view their personal information and may correct any errors.