APPLICATION FOR SPECIAL LICENCE

Form 6, Section 138, Sale and Supply of
Alcohol Act 2012

For Council use
File #

Send or deliver your application to:
The Secretary

District Licensing Committee
Kāpiti Coast District Council
Private Bag 60601, Paraparaumu 5254
175 Rimu Road, Paraparaumu 5032
Telephone (04) 296 4700 Toll Free: 0800 486 486 Email: licence.application@kapiticoast.govt.nz

Before you start, please check that you have everything you will need:

☐	Applications must be submitted at least 20 working days before the event or gathering. There are some exceptions to this rule such as for a funeral but not for pre-planned events, so get your application in as soon as possible.
☐	Please complete all sections that relate to the type of special licence for which you are applying.
☐	Your application will not be formally accepted until you have completed the application in full and paid the appropriate fee.
☐	Attach a licensed area floorplan or site map.

This application is made in accordance with the particulars set out below.
1. Type of Special Licence Applied For and whether event foreseeable
☐ On-site Special Licence allows the sale and supply of alcohol that will be consumed at the event, OR ☐Off-site Special Licence allows the sale and supply of alcohol that will be taken away and consumed at another place. This also allows free samples to be supplied. An off-site special licensee can only sell their alcohol (for example, a winery can sell the wine they produce).
Is this application being made at least 20 working days before the start of the event? ☐Yes ☐ No, and if ‘No’, provide a reason why the need for a special licence could not reasonably have been foreseen earlier.
2. Details of Applicant
Full legal name or names to be on licence:
Whether licence already held for premises or conveyance concerned: ☐Yes ☐No, and if ‘Yes’, state kind of licence and licence number:
3. Applicant Status by reference to section 28 of Sale and Supply of Alcohol Act 2012
☐Natural Person(s) ☐Body Corporate	☐Partnership ☐Incorporated Society	☐Private Company ☐Public Company	☐Other (please specify)
4. For Applicant that is a Natural Person or Persons
Full legal name:
Any aliases (and/or maiden name):
Usual residential address: Number	Street:
Suburb:	City:	Postcode:
Sex:	Occupation:
Date of birth:	Place of birth:
Telephone:	Email:
Mobile:	Preferred mode of contact:
5. For Applicant that is a Body Corporate, Authority under which Incorporated
6. For Applicant that is Not a Natural Person(s), Details of Contact Person
Name:
Telephone:	Email:
Mobile:	Preferred mode of contact:
7. Postal Address for Service
Number/Street/PO Box:	Suburb:
City:	Postcode:
8. Business Details
Describe principal business, any other businesses. If you are not a business but are representing a group please advise name of group and your position in that group.
9. Criminal Convictions
Does the applicant(s) have any criminal convictions (other than convictions for offences against provisions of the Land Transport Act 1998 not contained in Part 6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies). ☐Yes ☐ No, and if “Yes”, then please provide nature of the offence, details of conviction, and penalty imposed.
10. Details of Duty Managers If you do not have certified managers, provide full names of supervisors and write ‘Supervisor’ in the manager’s certificate box
Full legal name:
Number of manager’s certificate:	Expiry Date:
Full legal name:
Number of manager’s certificate:	Expiry Date:

11. On-site Special Licence
11a. Details of premises (On-site Special Licence)
Address of premises: Number	Street:
Suburb:	City:	Postcode:
Any name, trading name, or name of building:
Tenure: (state whether to be held as leasehold, freehold, unit title, under tenancy agreement, or other)
Is the licence conditional on completion of building work: ☐Yes ☐No, and if “Yes”, state details
OR 11b Details of conveyance:
Type of conveyance: (i.e. aircraft, coach, ferry, ship, train, or other vehicle used to transport people)
Any registration number:
Any home base address: Number	Street:
Suburb:	City:	Postcode:
Any name used or proposed for conveyance:
12. Event Details (On-site Special Licence)
Describe name and the nature of event. If wedding/birthday/anniversary function please give name(s) of person(s):
State the days and hours proposed for sale of alcohol: When including attachments please number the hard copies and write the document number here‘ #.
The number of people attending is estimated to be:
The probable age distribution of people attending is:
The principal purpose of event is:
Is the applicant intending to engage in the sale or supply of any goods other than alcohol, non-alcoholic refreshment and food, or in the provision of any services other than those directly related to the sale and supply of alcohol and food ☐Yes ☐No, and if “Yes”, state nature of other goods and services
The types of container in which alcohol is intended to be sold:
13. Conditions – (On-site Special Licence) Write answer below or attach relevant documents that demonstrate compliance. When including attachments please number the hard copies, and put the document number in the right hand column.	Doc attached? Number.
Describe experience and training of applicant:	#
Describe the type and range of food intended to be available for purchase:	#
Describe the type and range of non-alcoholic beverages intended to be available for purchase:	#
Describe the type and range of low-alcohol beverages intended to be available for purchase:	#
Describe to what extent, and where, drinking water is intended to be freely available to patrons (if no access to mains water supply, also advise the potability of water intended to be available):	#
Describe the steps intended to be taken to provide help with and information about transport options from the premises:	#
Describe the steps proposed to be taken to prevent the sale and supply of alcohol to prohibited people:	#
Describe any other steps the applicant proposes to promote the responsible consumption of alcohol (for instance host responsibility practices):	#
How many Duty Managers will be working at the function/event? How many other staff?	#
Describe any other systems (including training systems), and staff in place (or to be in place) for compliance with the Act:	#
Describe any music (live band, DJ, stereo) or potential noise source:	#
Describe any actions that you intend to take to ensure the good order and amenity of the locality would not be likely to be reduced, by more than a minimal extent, by granting the licence . This includes issues such as noise (including amplified music, people in outdoor areas or arriving or leaving premises), the effects on sensitive users within locality such as pre-schools, schools and medical centres, and the levels of nuisance and vandalism.	#

14. Attachments (On-site Special Licence) When including attachments please number the hard copies, and put the document number in the right hand column.	Doc attached? Number.
Please attach floor plan of the licensed area. Please indicate whether the licensed area is to be undesignated, supervised or restricted and show the principal entrance.	#
Advise if a Crime Prevention Through Environmental Design (CPTED) assessment has been undertaken or any improvements to the design and layout in accordance with CPTED. ☐ Yes ☐ No, and if ‘Yes’ attach a copy.	#
End of On-site Special Licence Application - Go to Section 19. Signature of Applicant
15. Off-site Special Licence
15a. Details of premises (Off-site Special Licence)
Address of premises: Number	Street:
Suburb:	City:	Postcode:
Any name, trading name, or name of building:
Tenure: (state whether to be held as leasehold, freehold, unit title, under tenancy agreement, or other)
Is the licence conditional on completion of building work: ☐Yes ☐No, and if “Yes”, state details
Does the applicant own the proposed licensed premises: ☐ Yes ☐ No, and if ‘No’, answer questions regarding the owner and tenure below.
Full legal name of owner:
Address: Number	Street:
Suburb:	City:	Postcode:
State form of tenure of premises applicant will have (including term of tenure):
Parts (if any) of the premises the applicant intends should be designated as a restricted area or a supervised area. Attach plan as appropriate.	Plan attached? #
OR 15b Details of conveyance
Type of conveyance: (i.e. aircraft, coach, ferry, ship, train, or other vehicle used to transport people)
Any registration number:
Any home base address: Number	Street:
Suburb:	City:	Postcode:
Any name used or proposed for conveyance:
16. Event Details (Off-site Special Licence)
Describe the name and nature of event:
State the days and hours proposed for sale of alcohol:
The number of people attending is estimated to be:
The probable age distribution of people attending is:
The principal purpose of event is:
Is the applicant intending to engage in the sale or supply of any goods other than alcohol, non-alcoholic beverages and food, or in the provision of any services other than those directly related to the sale and supply of alcohol and food ☐Yes ☐No, and if “Yes”, state nature of other goods and services. This is to assess whether other goods and services provided are compatible with the sale of alcohol.
The types of container in which alcohol is intended to be sold:
17. Conditions – (Off-site Special Licence) Write answer below or attach relevant documents that demonstrate compliance. When including attachments please number the hard copies, and put the document number in the right hand column.	Doc attached? Number.
Describe experience and training of applicant:	#
Describe any other systems (including training systems), and staff in place (or to be in place) for compliance with the Act:	#
Describe the steps proposed to be taken to prevent the sale and supply of alcohol to prohibited people:	#
How many Duty Managers will be working at the function/event? How many other staff?	#
Describe any other steps the applicant proposes to promote the responsible consumption of alcohol (for instance host responsibility practices):	#
Describe any music (live band, DJ, stereo) or potential noise source:	#
Describe any actions that you intend to take to ensure the good order and amenity of the locality would not be likely to be reduced, by more than a minimal extent, by granting the licence. This includes issues such as noise (including amplified music, people in outdoor areas or arriving or leaving premises), the effects on sensitive users within locality such as pre-schools, schools and medical centres, and the levels of nuisance and vandalism.	#
18. Attachments (Off-site Special Licence) When including attachments please number the hard copies, and put the document number in the right hand column.	Doc attached? Number.
Please attach site map or floor plan of the licensed area. Please indicate whether the licensed area is to be undesignated, supervised or restricted and show the principal entrance.	#
19. Signature of Applicant (This must be signed by applicant not their agent) If you are applying electronically, your digital signature is the legal equivalent of your manual signature on this application. By selecting this method you consent that the information provided in this application is true and correct.
Name:	Position/Job title:
Signature:	Date:
Privacy Statement
Information contained in your application and any supporting information will be held by Kapiti Coast District Council to enable your application to be processed under the Sale and Supply of Alcohol Act 2012. This information will be made available to the public on request. The information will be provided to the Kapiti Coast District Licensing Committee, the NZ Police, the Medical Officer of Health and Council’s Licensing Inspectors. This information may form part of a public hearing of your application before the Kapiti Coast District Licensing Committee and may be used in the Committee’s decision for your application. Decisions will be made publically available. Council is required to keep a statutory register of all applications and the District Licensing Committee’s decisions on them. Council is required to report statistics about applications to the Alcohol Regulatory and Licensing Authority. Any member of the public may request access to this information under the Local Government Official Information and Meetings Act 1987. This information may also be used under the Privacy Act 1993. You have the right to see and correct personal information that Council holds about you.

Notes

This form must be accompanied by the prescribed fee. Go to http://kapiticoast.govt.nz/services/A---Z-Council-Services-and-Facilities/Fees-and-Charges/liquor-licensing-fees/ for more information.

Payment of the fee can be made online using the following instructions:

Name	Kapiti Coast District Council
Bank	Westpac
Branch	Paraparaumu
Account Number	03-0732-0306101-00
Reference:	Alcohol – your name

If required to do so by the Secretary of the District Licensing Committee, the applicant must, within 10 working days after filing this application with the committee, ensure that notice of this application in Form 8 is attached in a conspicuous place on or adjacent to the site to which this application relates.

Guidance for Completing Application for a Special Licence Form

Background
The object of the Sale and Supply of Alcohol Act 2012 is that the sale, supply, and consumption of alcohol should be undertaken safely and responsibly; and the harm caused by the excessive or inappropriate consumption of alcohol should be minimised. It is a legal requirement of the Sale and Supply of Alcohol Act 2012 that you must have a licence before you can sell and supply alcohol.
Application must be made 20 working days before event
If your application has been lodged less than 20 working days before the event, the Licensing Inspector cannot process the application without sign off from the District Licensing Committee. You must provide a reason why the need for a special licence could not reasonably have been foreseen earlier.
Definitions:
Natural Person: an ordinary person who is applying for a special licence for a private event, or on behalf of a group or community organisation (usually for fundraising purposes) Not a Natural Person: Body Corporate, Partnership, Private Company or Public Company On-site Special Licence: allows the sale and supply of alcohol that will be consumed at the event. OR Off-site Special Licence: allows the sale and supply of alcohol that will be taken away and consumed at another place. This also allows free samples to be supplied. An off-site special licensee can only sell their alcohol (for example, a winery can sell the wine they produce). Conveyance: A ‘conveyance’ is a premises which is used to transport people such as an aircraft, coach, ferry, hovercraft, ship, train, or other vehicle OR Premises (not a conveyance): any other type of premises (building or open space) that is not a conveyance for which you are seeking a Licence.

For Office Use: Customer Service Desk Checklist: Fee has been paid Attachments checked? CSO has checked that all identified (Yes/No Ref # …..) attachments are attached OR CSO has NOT checked that all identified documents are attached Signature of CSO_____________________________________________________________________Date:_____________________