FAR NORTH DISTRICT COUNCIL Year 2000 Form A4 b) To: The Secretary District Licensing Agency Private Bag 752 KAIKOHE APPLICATION FOR SPECIAL LICENCE (CONVEYANCE) Sections 76, Sale of Liquor Act 1989 Application for a Special Licence is made in accordance with the details set out below. 1. DETAILS OF APPLICANT Full Name(s): Postal Address for service of documents: Fax Number Telephone Number Daytime Contact Name Daytime Telephone Email Address Full name and address of manager or managers to be employed, and certificate numbers of manager s certificate(s): Status of applicant [tick appropriate box] Natural person Private Company Public Company Partnership Trustee Local Authority Government Department or other instrument of Crown Licensing trust Body corporate to which section 75(ba) of the Act applies (i.e. incorporated club): Board, organisation, or other body to which section 75(bb) of the Act applies (i.e. unincorporated club): Manager under the Protection of Personal and Property Rights Act 1988 2. CONVEYANCE DETAILS Type of Conveyance: Address of Home Base: (if any) Principal Route Travelled: (if any) Proposed trading name for conveyance (if any): Is the Licence sought conditional upon construction or completion of the conveyance? Yes No Does the applicant own the conveyance? Yes No If No What is the full name and address of Owner? What form of tenure of the conveyance will the applicant have? (including term of tenure)
PREMISES DETAILS CONTINUED What part (if any) of the conveyance does the applicant intend should be designated as A Restricted Area A Supervised Area 3. PURPOSES (To be completed only where the application is made for a licence under Section 73 of the Act) What is the occasion or event, or series of occasions or events, in respect of which the licence is sought When is this occasion or event, or series of occasions or events, to occur? On which days and during which hours does the applicant intend to sell liquor under the licence? 5. CONDITIONS What provision does the applicant intend to make for the sale and supply of: i) Food ii) Non-alcoholic Refreshments iii) Low-alcohol Beverages What steps does the applicant propose to take to provide assistance with or information about alternative forms of transport from the licensed premises? What steps does the applicant propose to take aimed at promoting the responsible consumption of liquor? What steps does the applicant propose to take to ensure that the requirements of the Act in relation to the sale of liquor to prohibited persons are observed? What containers does the applicant propose to sell liquor in? Dated at this day of 201 Signed by Applicant
NOTES ON APPLICATION FOR SPECIAL LICENCE FOR CONVEYANCE 1. An application for a special licence for a conveyance shall be made on Form A4 b). For single one-off occasions, lodgement of this application must be made at least 20 working days prior to the event. Where an application seeks a licence for multiple dates, then a greater period should be allowed as public notification and/or an Agency hearing may be required. 2. Every application for a special licence shall be accompanied by the following: a) Two copies of the application with accompanying documents. b) Where the applicant is a board, organisation, or body to which Section 75(bb) of the Act applies, a reference to the Act under which the applicant is authorised to sell liquor or hold an on-licence under the Act. c) Where the applicant is a manager acting for any person pursuant to a property order made under the Protection of Personal and Property Rights Act 1988, a copy of the property order. d) Where the applicant is a club and holds a club licence under the Act, the number of the club licence shall be provided. e) Where the applicant is a club but does not hold a club licence under the Act: i. An incorporated club - copy certificate of incorporation or other documentary evidence of incorporation. ii. A chartered club - identifying particulars of the club's charter. iii. A copy of the club's constitution or rules. f) Where the application is made under Section 74 of the Act, identifying particulars of the onlicence or club licence held shall be provided. g) A plan showing: i. Those parts of the conveyance that are to be used for the sale or supply of liquor and ii. Those parts of the conveyance (if any) that the applicant intends should be designated as restricted areas or as supervised areas. h) Where the applicant is not the owner of the conveyance, a written statement from the owner to the effect that the owner has no objection to the grant of the licence shall be provided. i) The prescribed fee of $64.40 3. The Secretary of the District Licensing Agency may require public notification of any application. If such notification is required, the applicant must, within 10 working days after filing the application, ensure that notice of the application in the prescribed form as shown below as an example of Form 1A, is attached in a conspicuous place on or adjacent to the conveyance or its home base to which the application relates:
Example of Site Notice...[Full name, address, and occupation of applicant] has made application to the District Licensing Agency at Kerikeri for the grant of a Special Licence in respect of the.. [Specify type of conveyance] known as... The general nature of the business to be conducted under the licence is...... (Specify details of occasion or event) The days on which and the hours during which liquor is intended to be sold under the licence are...... The application may be inspected during ordinary office hours at the office of the Far North District Licensing Agency at level 2, FNDC John Butler Centre, 60 Kerikeri Road, Kerikeri. Any person who is entitled to object and who wishes to object to the grant of the application may, not later than 10 working days after the date of the first publication of this notice, file a notice in writing of the objection with the Secretary of the District Licensing Agency at Private Bag 752, Kaikohe.
Name: NEW ZEALAND POLICE SUPPLEMENT As applicant for this Licence Certificate, you are requested to sign the authorisation below. Failure to allow Police to disclose this information may result in your application only being determined at a hearing held by the Liquor Licensing Authority where you will be required to attend and present the information for this Authority s consideration. AUTHORISATION The Police are required to report on this application. That report may include the release of any previous convictions you may have. You will receive a copy of that report. Do you consent to the release of this information? YES / NO SIGNATURE OF APPLICANT: DATE: NOTE: The Criminal Records (Clean Slate) Act 2004 applies to this application.