Health Premises
Public Health and Wellbeing Act 2008 /
Council Use Only
Office Received Date :
Registration Number:
Debtor Number:
Receipt Number:
Fields marked with an asterisk (*) are mandatory and must be completed.
Moving Registered Premises Address Section ONLYNEW PREMISES: Continue to Applicant Details.
EXISTING PREMISES If you have a current Yarra Ranges Health registration and moving address please complete this application. No fees apply (Except for Hairdressers – Please see information below)
From 1 March 2016 proprietors of hairdressing and low risk beauty therapy premises are able to apply for an on-going registration. Proprietors moving premises are required to submit this application along with the on-going registration fee of $130.00.
Registration No.
£ MOVING PREMISES OR £ HAIRDRESSER MOVING PREMISES
(No fee applicable) ($130.00 ongoing registration fee applicable)
DECLARATION (please read and tick):
£ As proprietor(s) signing this application I/we understand that by completing this form the health registration stated above with former premises will be closed.
IMPORTANT: If you are planning to continue trading in your current premises while your new premises is being constructed or fit out is occurring – do not complete this form yet. Health Officer assessment and inspections during construction/fit out is available prior to registration by completing the Submitting Plans for Health/Accommodation Premises Form including a copy of plan (fees apply). For form, visit www.yarraranges.vic.gov.au and search for Health Officer Consultation and Inspections or contact Public Health on 1300 368 333.
Applicant Details
Proprietor Is this proprietor a contract for this application? Yes/No
(If there is more than one proprietor of the business, complete details for each below) / If ‘no’ please complete the Contact section below
Title* / Surname* / Given Names *
ABN / ACN
Business Name / Company Name
Address
PO Box / GPO Box / Private Bag / Locked Bag / RRN / RSD
Street Address/ Postal Address*
Suburb / Town* / State * / Postcode *
Please provide at least one phone number and include the area code *
Business Phone / After hours phone / Business Fax / Mobile
() / () / () / ()
Proprietor 2 (if applicable)
Title* / Surname* / Given Names *
ABN / ACN
Business Name / Company Name
Address
PO Box / GPO Box / Private Bag / Locked Bag / RRN / RSD
Street Address/ Postal Address*
Suburb / Town* / State * / Postcode *
Please provide at least one phone number and include the area code *
Business Phone / After hours phone / Business Fax / Mobile
() / () / () / ()
Proprietor 3 (if applicable)
Title* / Surname* / Given Names *
ABN / ACN
Business Name / Company Name
Address
PO Box / GPO Box / Private Bag / Locked Bag / RRN / RSD
Street Address/ Postal Address*
Suburb / Town* / State * / Postcode *
Please provide at least one phone number and include the area code *
Business Phone / After hours phone / Business Fax / Mobile
() / () / () / ()
Email*
*Additional proprietors please provide as an attachment with contact details.
Contact detailsContact for this application
Title* / Surname* / Given Name(s) *
ABN / ACN
Business Name / Company Name
Address
PO Box / GPO Box / Private Bag / Locked Bag / RRN / RSD
Street Address *
Suburb / Town / State / Postcode
Business Phone / After hours phone / Business Fax / Mobile
() / () / () / ()
Premises details
Address
Street Address / Postal Address *
Suburb / Town * / State * / Postcode *
Primary Language Spoken at Premises (to assist with communication in the future)
Health Premises Activities
Please choose the activities your business conducts* (Please select ALL that apply):
Class A (High Risk Activity Category)
£ Tattooing / £ Body Piercing / £ Dry Needling / £ Electrolysis
Class C (Medium Risk Activity Category)
£ Nail Treatment / £ Facials / £ Ear Piercing / £ Waxing
£ Laser Treatment / £ Threading / £ Mobile Beauty Treatment (excl. Class A activities)
Class D (Low Risk Activity Category)
£ Hairdressing / £ Barber / £ Mobile Hairdressing / £ Low Risk Beauty*
(*Low Risk beauty includes temporary make-up, spray tans, henna tattoos, eyelash & eyebrow tinting)
NOTE: If your application is for Class D low risk activities only, the registration will be ongoing and there is no expiry date.
£ Other*
*Classification to be determined. Please contact Public Health Services.
Mobile Details
If any part of the business is a Mobile Health Premises, please include details below.
Health vehicle details (if applicable)
Registration number Make Model
Note: Mobile personal care and body art businesses that conduct skin penetration are not permitted. Any additional vehicle(s) details are to be added as an attachment.
Mobile vehicles to be registered at your primary place of business or where vehicle is based.
Supporting documents
There are no attachments if you have a template standard food safety program
Floor Plan* Only (1) Copy. If providing attachment electronically, please supply as: doc;pdf
Submit A4 or A3 plans at a scale of 1:100 of the premises layout showing all fittings and fixtures (including toilets, sinks, etc.)
Please Note: If you have previously lodged Submitting Plans for Approval for a Food, Health or Prescribed Accommodation Premises for the premises you are registering and those plans are still current then a new Floor Plan will not be required.
Additional Information As Requested By Council Only 1 Copy.
If providing attachment electronically, please supply as: doc;pdf
If you have discussed this application with Council prior to delivering the application to Council, Council may request additional information based upon the nature of the application.
IMPORTANT: Failure to provide plans will result in delays in the processing of your application.
Payment Details
The fee for health registration depends upon your type of business. Listed below are the applicable fees. Pro-rata applies dependant upon lodgement date. Renewal fees are same as listed under 1 January due at start of each calendar year. The fees are based upon the classes/classifications given by Yarra Ranges Shire Council.
Fees current for 2016-2017 Financial Year. Fees are exempt from GST.
Visit www.yarraranges.vic.gov.au for more information.
Class A Pro Rata 1 July 2017 - 31 December 2017 / $149.00
Full Fee From 1 January 2018 / $298.00
Class C Pro Rata 1 July 2017 – 31 December 2017 / $80.00
Full Fee From 1 January 2018 / $160.00
Class D Pro Rata (no pro-rata)
Full Fee From 1 July 2017 / $130.00
Note: Classification and fee is determined on highest class activity selected in Health Premises Activities.
How to Pay:
In Person: By cash, cheque or credit card.
By Mail: Cheque ONLY
If you are unsure of the amount to pay, please contact Public Health on 1300 368 333.
Declaration
I understand and acknowledge that:
- The information provided in this application is true and complete to the best of my knowledge
- This application forms a legal document and penalties exist for providing false or misleading information
- I am over 18 years at the time of completing this application
By marking this checkbox I confirm that I have read and understood all the statements above *
Name of person completing this application * / Date *
Signature of person completing this application *
Privacy Statement
The information gathered in the form is used by Council to process the application. To view Council's privacy policy, please either visit Council's offices or go to www.yarraranges.vic.gov.au.
Lodgement
Please post this form to:
Yarra Ranges Shire Council Telephone: 1300 368 333
Public Health Services Fax: 03 9735 4249
PO Box 105 Email:
LILYDALE VIC 3140 Website: www.yarraranges.vic.gov.au
OR deliver to:
Lilydale
15 Anderson St /
Upwey
40 Main St /
Monbulk
21 Main Rd /
Healesville
110 River St /
Yarra Junction
2442-2444 Warburton Hwy (cnr Hoddle St)
Page 3 of 5
1 July 2017