Postal Address Environmental Health Internet

PO Box 159 Ph: 07 3205 0555

Caboolture QLD 4510

ABN:92 967 232 136

Food business details:

Name of licensee:

/
Name of food business:
Address of food business:
Food business licence number:
Business phone:
Email address:

Note: Contact details which you provide may be used to update council’s records.

Application type:
Note: Any change of food safety supervisor must be provided in writing to Council within 14 days of the change.

Is this a request to add a food safety supervisor: Yes No

Is this a request to remove an existing food safety supervisor: Yes No

Is this a request to update the details of a previously nominated food safety supervisor: Yes No

Please provide details of change (e.g. name of person to be removed) in box below:

Food safety supervisor details:

.

First name: / Surname:
Address:
Home number: / Mobile phone: / Work phone:
Email address:

Note: Contact details which you provide may be used to update council’s records.

Details of qualification (Provide details of national competency codes and attach copy of qualification to this form):

Do you have morethan one food safety supervisor:

Yes - complete the above details on a separate sheet and return with this form and a copy of their qualifications

No

Signature of licensee:
I, / certify that the above information and the information on any attachments,
to the best of my knowledge, is correct.:
Signature of licensee: / Date:
Submission options:

In person –Present this form at any of the Moreton Bay Regional Council Customer Service Centres:

Caboolture: 2 Hasking Street, Caboolture | Strathpine: 220 Gympie Road, Strathpine | Redcliffe: Irene Street, Redcliffe
By mail – PO Box 159, CABOOLTURE QLD 4510.. By email -

Privacy statement

Moreton Bay Regional Council is collecting your personal information for the purpose of maintaining food safety supervisor details. The collection of this information is authorised under the Food Act 2006. Your information will not be given to any other person or agency unless you have given us permission or we are required by law.