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Application to Register Prescribed

Accommodation Premises

Public Health & Wellbeing Act 2008

 

Environmental Health Services

Brimbank City Council

PO Box 70  

Sunshine Victoria 3020

Ph: 03 9249 4000

 

 

http://www.brimbank.vic.gov.au

 

In order for the application to be assessed you will need to fill in all sections of this form.

Failure to complete the form may delay the registration process.

 

 

APPLICANT – PERSON / COMPANY SUBMITTING APPLICATION / PLANS

 

 

 

 

¡ Project Manager

¡ Builder

¡ Drafts Person

¡ Sole Proprietor

¡ Company

 

Title*   Given Name*         Surname*

 

 

*If the proprietor is a company or association the company name will need to be filled in below

 

 

or

Company Name (If applicable)

 

 

 

Street Address *

 

 

Suburb/Town*             State*     Postcode*

 

 

 

Business Phone*   After Hours Phone* Mobile Phone*

 

Email address*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPRIETOR / OWNER DETAILS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¡ Sole Proprietor

¡ Partnership

¡ Company

 

 

Title*   Given Name*         Surname*

 

 

 

*If the proprietor is a company or association the company name will need to be filled in below

 

or

 

Company Name (If applicable)

 

 

 

Home / Registered Address *

 

 

Suburb/Town*     State*     Postcode*

 

 

 

Business Phone*   After Hours Phone* Mobile*    

 

 

Email address*

 

 

 

 

Street or Po Box  

 

 

Suburb/Town     State   Postcode

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREFERRED ADDRESS FOR POSTAL CORRESPONDANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREFERRED CONTACT PERSON

 

 

 

 

 

 

 

Title* Given Name* Surname*

 

 

 

Position*

 

 

Contact phone*

 

 

 

 

 

 

 

 

 

 

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREMISES DETAILS

 

 

 

 

House / Motel / Hotel - Trading Name*

 

           

 

Street address*

 

 

Suburb/Town*     State*       Postcode*

 

 

 

ABN*

 

 

Business Telephone* (preferably the site phone number)

 

 

 

 

¡ Number of rooms image

 

¡ Number of Beds - Single image

¡ Number of Beds - Double / Queen / King image

¡ Number of People at full Occupancy image

 

 

 

 

Estimated Date of Construction

 

Estimated Date of Completion

 

Proposed Opening Date

 

 

 

 

Please note:

 

 This application is for the above nominated premises for Registration under the Public Health & Wellbeing Act 2008.

 

 You must contact the Brimbank City Council’s Planning and Building departments (or a private Surveyor) to ensure that you have the correct permits to commence your business.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE NOTE

 

 

 

 

This application is for application for registration under the Public Health & Wellbeing Act 2008 only.

 

You may be required to consult with other departments within Council and externally to ensure that you meet their requirements.

 

 Have you contacted Council’s building department about this application: Yes ¡ No ¡  

Have you contacted Council’s planning department about this application: Yes ¡ No ¡

Signature:  

 

Date:

 

To contact Building/Planning departments please contact Brimbank City Council on

03 9249 4000

 

 

 

 

 

FEES

 

 

 

 

Please contact the Environmental Health Department on 03 9249 4000 for the correct fee prior to submitting this form.

 

 

 

Office use only Debtor Number: ________________________  

 

 

 

 

 

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By mail (cheque or money order only).

Send the completed and signed form with your cheque or money order payable to:

 

Brimbank City Council

PO Box 70, Sunshine Vic 3020

 

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In person

 

Present the completed and signed form to make payment (eftpos, cash, visa, master card, cheque or money order)

 

At one of our Customer Service Centres

 

301 Hampshire Road, Sunshine

(Brimbank Community & Civic Centre)

 

Keilor Community Hub

704B Old Calder Hwy, Keilor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DECLARATION

 

 

I understand and acknowledge that:

 

•  The information provided in this application is true and complete to the best of my knowledge

•  This application is a legal document and penalties exist for providing false or misleading information

•  Please ensure that you have completed the form and have attached the requested information. Failure to do this may

 

 

Proprietor Signature            Proprietor Signature

 

 

 

 

Print Proprietor Name          Print Proprietor Name

 

 

 

 

Date                Date

 

 

 

 

 

PRIVACY

 

 

 

The personal information requested on this form is being collected by Council for the purpose of meeting its legal obligations under the Public Health and Wellbeing Act 2008 and associated or related legislation. The information will be kept confidential and identifying information will not be disclosed to any person for any other purpose. You may access your own information by contacting Council’s Environmental Health Services on 9249 4000.