Public Health Premises Notification

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Public Health Premises Notification Form

Public Health Act 2010

Applicant Details

(Details of person submitting form)

Full Name

Phone

Premises Details

Business Trading Name

Premises Trading Address (address where activity occurs)

Phone

Trading Days/Hours

Note: This notification does not constitute consent or preclude the need for development consent under the EP&A Act 1979 or the Local Government Act 1993.

Operator Company Details

Company Name

Operator Full Name

Mailing Address

Phone

ABN/ACN

Business Contact Person (if different from above)

Applicant Declaration

I declare that to the best of my knowledge, the information provided in this application is accurate and correct. I am aware that I will be required to pay a fee for public health premises inspections undertaken by Council, which will be charged in accordance with the most recent Wollondilly Shire Council's Fees and Charges Schedule.

I agree

Proprietor Signature (Use your mouse or finger to draw)

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