Food Safety Supervisor

Notification or change of details form

Food Act 2006
For enquires regarding this form please contact Council’s Environmental Health and City Law Services on (07) 5667 5988.
Please use BLOCK LETTERS and complete all details in full. / Council of the City of Gold Coast
ABN 84 858 548 460
PO Box 5042 GCMC QLD 9729
P 1300 GOLDCOAST
F 07 5596 3653
E
Wcityofgoldcoast.com.au
Section 1 - Application type
Notification of new Food Safety Supervisor / Notification – no longer a Food Safety Supervisor
Change to existing Food Safety Supervisor details
Section 2 - Food business details
Licence number
Trading name
Premises address
Licensee name
Postal address
Phone / Mobile
Email
Section 3 - Food safety supervisor/s
Nominated food safety supervisor
Phone / Mobile
*For additional Food Safety Supervisors, provide the above details in an attachment to this form.
Section 4 - Licensee declaration (must be completed by the licensee)
I understand and acknowledge that:
  • It is an offence to knowingly provide false or misleading information;
  • Documentation must be provided if a power of attorney (POA) signs on behalf of a person;
  • A person signing on behalf of a corporation or incorporated association must occupy a position that is legally entitled to make an application on behalf of that corporation or incorporated association.

Licensee name
Signature / Complete when signing on behalf of person or organisation
Signatory name
Date / Position (eg. CEO)
Section 5 - Fees
No fees are required for this notification.

Privacy statement

Council of the City of Gold Coast is collecting your personal information in accordance with Food Act 2006 in order to assess your notification. The information will only be used by authorised officers for the purpose of administering licenses and approvals on the Gold Coast. Your information will not be given to any other person or agency unless you have given us permission or we are required or allowed to by law.

Office use only
Date received / Fee paid
Received by / Receipt number
Application approved / Account number