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*
PREMISES DETAILS
House / Motel / Hotel - Trading Name*
Street address*
Suburb/Town* State* Postcode*
ABN*
Business Telephone* (preferably the site phone number)
¡ Number of rooms
¡ Number of Beds - Single
¡ Number of Beds - Double / Queen / King
¡ Number of People at full Occupancy
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: ________________________
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
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.
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.