Public Health Risk Activity Application (Premises)

Use this form if you are operating a premises where a public health risk activity is to be conducted.

Are you applying as:

An individual

A company or registered business

Name of applicant(Required)

First Last

ABN/ACN(Required)

Contact Person

Date of Birth

(for non-ABN/ACN holders)

Phone(Required)

Email(Required)

Address of applicant(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Registered address(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Address of applicant(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Relationship to the Business(Required)

Your role in Company(Required)

Is your postal address different from above?(Required)

Yes

Postal address

Street Address Address Line 2 City State / Province / Region Post Code

Business Details

Business Trading Name(Required)

Where the applicant will be carrying out this activity

Business Name(Required)

Depicted on the street frontage of the premises

ABN/ACN

Premises Address(Required)

Street Address Address Line 2 City State / Province / Region Post Code

Postal Address

Street Address Address Line 2 City State / Province / Region Post Code

If different from above

Name of Business Manager

First Last

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

What Public Health Risk Activities do you propose to conduct on these premises?(Required)

Provide names of those licensed to carry out a Public Health Risk Activity at your premises.(Required)

Have the staff that conduct the Public Health Risk Activity been vaccinated against Hepatitis B?

Yes

What training or experience do you require your staff to have in relation to infection control?

Please attach supporting evidence e.g. Certificate of Achievement.

File

Drop files here or

Max. file size: 20 MB.

The personal information on this form is required by Clarence City Council for the Registration of a Public Health Risk Activity (Person) under the Public Health Act 1997. We will only use your personal information for this and related purposes. If this information is not provided, council may not be able to process this application. You may access and/or amend your personal information at any time. How we use this information is explained in our Privacy Policy, which is available at www.ccc.tas.gov.au/privacy or at Council Chambers.

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