Approvals Group

New Zealand Food Safety

Ministry for Primary Industries
Charles Fergusson Building, 34-38 Bowen St, Pipitea
PO Box 2526, Wellington, New Zealand 6140 Tel: 04 894 2550
Email: [email protected]

Application Form FA10C

New Custom Food Control Plan under Food Act 2014

Before you start, let’s check that you have everything you need:
• If your food control plan (FCP) has been developed using the MPI "My Food Rules" tool, copies of:
- the MPI interview report; and
- the My Food Plan document, including site plan or plans, for your business.

• If your FCP is customised or has customised parts, copies of:

- the report from an evaluator endorsing your customised FCP. A list of recognised evaluators can be found
here: https://www.mpi.govt.nz/food-business/food-safety-registers-lists/ ; and
- the endorsed FCP, including site plan or plans, for your business. If you need help developing your FCP,
visit the MPI website.

• A description of your business scope of operations. Find more information and a form to fill in by visiting
https://www.mpi.govt.nz/food-business/running-a-food-business/, Forms & documents, Scope of Operations.
• A copy of the confirmation letter from your verifier. A list of recognised verification agencies can be found here:
https://www.mpi.govt.nz/food-business/food-safety-registers-lists/ .

• If your business is a registered limited liability company, a copy of the company registration certificate and
your New Zealand Business Number (NZBN). See www.companies.govt.nz
• If your business is a multi-site operation, registration information for every address (see section 5). Multi-site
means there is more than one address where food is traded, and that you would like to register all sites under
one application. A spreadsheet of the sites’ information attached to your application is acceptable. You need to
make sure you can confirm that every operator of the food businesses covered by the food control plan is
resident in New Zealand within the meaning of section YD 1 or YD 2 (excluding section YD 2(2)) of the Income
Tax Act 2007, and that you include company registration certificates for any limited liability companies.
• Your application fee of $349.31 (incl. GST).

Read these notes before you start filling out the form
• This form must be used when applying to MPI for registration of a custom FCP under section 53 of the Food Act
2014. Some information provided will be included on the public register; however, you can ask for certain
personal information to be withheld from the published register. We will tell you where you can choose that
option. You can view the public register here: www.mpi.govt.nz/food-safety/food-act-2014/, Registers & lists.
• Send the completed application form together with the fee and other requirements above to MPI at the above
address. We prefer email files. Processing time is up to 20 working days from the time we determine that
your application is complete.

• This icon is used when you need to make a decision. The question will help you decide whether you need
to complete a particular section.
• Throughout this form you will need to tick boxes that look like this: . A checked box indicates a 'yes' answer.
• If there are any changes to the details provided in this application after it has been sent to MPI, you must
promptly inform us of the changes in writing.
Approvals Group
New Zealand Food Safety
Ministry for Primary Industries
Charles Fergusson Building, 34-38 Bowen St, Pipitea
PO Box 2526, Wellington, New Zealand 6140 Tel: 04 894 2550
Email: [email protected]

Application Form FA10C

New Custom Food Control Plan under Food Act 2014
Processing time is up to 20 working days from the time we determine that your application is complete.

Question A: Have you previously been registered as a food business with

MPI or your local council?
Yes à Complete section 1.
No à Go straight to section 2.

Section 1. Previous registration IDs

If you have previously been registereded as a food business with MPI or your local council enter your registration ID number(s)

Section 2. Food Control Plan Operator Details

Enter the details of the person who is either the owner or person in control of the food business. If your food control plan applies to more
than one food business, the operator is the person responsible for the food control plan.
Legal Name(s) of
Operator
(e.g. registered
company, partnership I have attached a copy of the company name registration from the New Zealand Companies office
or individual) (www.companies.govt.nz)

New Zealand Business

Number (NZBN)

For more information about NZBN’s, including how to get one, see www.nzbn.govt.nz
Trading Name, if any
(i.e. ‘Trading As’)
Same as legal name above
Operator Address and Contact Details
You must provide this information to be registered. However, if the address is a dwelling/house, you may ask that the address is withheld
from the public register by ticking the box below.

Postal Address Physical / Courier Address (if different to Postal Address)

Address: Address:

Town/City: Town/City:
Postcode: Postcode:
Country: Country: New Zealand
This address is a private dwelling/house and I wish it to This address is a private dwelling/house and I wish it to
be withheld from the public register. be withheld from the public register.
Local Authority
(Council)
This is the council for
the operator physical
address
Contact Person Details
The contact person details entered below will be used for communications, such as sending approval documents and renewal reminders.
Contact MPI if the details change.
Email

By entering an email address you consent to being sent information and notifications electronically, if required.

Mobile telephone no. Other

telephone
no.
Operator day-to-day Name:
manager name and
position Position:

Section 3. Scope of Operations

Scope of Operations tells us more about what you do. The form is available online at www.mpi.govt.nz/food-business/running-a-food-
business/, Forms & documents, scope of operations. Please tick one option below.

I am applying to register a My Food Plan FCP. The scope is included in my FCP/interview report.
I have attached a completed Scope of Operations form providing a description of my business operations; or,
I have attached a written description of my business operations. This includes all of the following:
- the Food Act sectors I will operate in – for example, retail, food service, manufacturing
- my products – the type of food I will make or sell
- processes – how I will make my food
- trading operations – how and where I will sell my products

Section 4. Verification Agency details

Name of Verification Agency(ies):
MPI may contact your Verification Agency
directly to clarify any issues related to your I have attached a copy of the letter confirming my nominated Verification Agency(ies) will
registration provide verification services for my registration. Note: letter should list every site the agency(ies)
will provide verification services for. If too many to list, letter should state 'all sites'.

Question B: Does your application relate to a food handling site address

different from the address in Section 2? Or does your application relate to more than
one site where food is traded, and you would like to register all these sites under one
application?
Yes à Complete section 5.
No à Go straight to Question C.

April 2021 Page 3 of 7 FA10C: Custom Food Control Plan

 Section 5. Multi-site Address Details
Add additional rows as necessary or attach a file (e.g. spreadsheet) to application email with all of the information required below. Include all addresses where food is handled, and a site plan for each address. If you already included a food
handling site address in section 2, repeat it here.
Legal name(s) of site operator NZ Business Site trading name, if any Street/Physical Address (location of actual Vehicle Registration Site day-to-day Local
(e.g. registered company, partnership or (i.e. ‘Trading As’) place) numbers (mobile manager Council
individual) Number
(where (Tick box if you wish the address to be withheld businesses only) position/job title
(Tick box to confirm company registration from the public register because it is a private
certificate is attached for any Limited Liability applicable)
dwellinghouse)
Companies)
E.g. ABC Foods Limited ✔ E.g. Yummy CakesRUs, E.g. 123 Cakes Road, Faketown 1234 ✔
E.g. Store
Wellington Store Manager

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

Same as legal name

April 2021 Page 4 of 7 FA10C: Custom Food Control Plan

 Question C: Have you created your custom food control plan using the MPI
"My Food Rules" tool?

Yes à Complete section 6, then go straight to section 8.

No à Complete section 7, then go to section 8.

Section 6. My Food Plan custom FCP

I have had a My Food Plan interview (if so, please ensure you promptly confirm accuracy of the draft interview report when received)
Other (enter details below)

If you have questions about the My Food Plan process, please contact [email protected]

Section 7. Standard custom FCP

I have attached a copy of the evaluation report provided by my recognised evaluator.
I have attached a copy of the evaluator endorsed food control plan, including site plan(s).

Section 8. Applicant Statement

Complete for all applications. We accept PDF or scanned versions of signatures.
I confirm that:

1. I am authorised to make this application as the operator or a person with legal authority to act on behalf of the operator; and

2. The information supplied in this application is truthful and accurate to the best of my knowledge and belief; and

3. The operator is resident in New Zealand within the meaning of section YD 1 or YD 2 (excluding section YD 2(2)) of the Income
Tax Act 2007; and

4. The operator of the food business is able to comply with the requirements of the Food Act 2014.

Name Job Title

Signature Date

April 2021 Page 5 of 7 FA10C: Custom Food Control Plan

 Have you completed section 5 (multi-site address details)?
Yes à Complete section 9.
No à Go straight to section 10.

Section 9. Multi-Site Food Control Plans - Applicant Statement

We accept PDF or scanned versions of signatures.
I confirm that:
1. I am authorised to make this application on behalf of the operators listed in section 5; and
2. Every operator of the food businesses covered by the Food Control Plan is resident in New Zealand within the meaning of
section YD 1 or YD 2 (excluding section YD 2(2)) of the Income Tax Act 2007; and
3. Every operator of the food businesses covered by the Food Control Plan is able to comply with the requirements of the Food Act
2014.

Name Job Title

Signature Date

Section 10. MPI Service Charge

ON PAYMENT THIS BECOMES A TAX INVOICE GST No: 64-558-838

Custom Food Control Plan Registration 2.25 hours $349.31

Note: In addition to the application fee above, an assessment time fee based on an hourly rate of $155.25 (incl. GST) per hour or $38.81
(incl. GST) per 15 minutes may be charged in instances where applications take longer to process.
Payments comprising multiple fees must be supported by a remittance advice. Please attach your payment confirmation to this
application or send it separately to: [email protected]
PAYMENT OPTIONS: Payment must be made using credit/debit card or direct credit (MPI does not accept
cash). Please tick and fill in the appropriate section.

CREDIT/DEBIT CARD (preferred option):

1. To pay by credit card (Visa or MasterCard) go to https://www.mpi.govt.nz/food-safety/payments and follow the instructions.
I have attached my credit card payment receipt

DIRECT CREDIT:
1. Pay into Bank Account no. 03 0049 0001709 002
2. In the ‘Reference’ details, put the code: ‘Food Act {your Company name}’
3. Enter the date of deposit and your name (payer) below.

Date of Deposit Your Name (Payer)

April 2021 Page 6 of 7 FA10C: Custom Food Control Plan

 Section 11. Final Check and Document Package to send to MPI

Please ensure you have:

Attached the following:
Endorsed food control plan and evaluation report (for standard custom FCP applications)
Letter from verification agency
Company registration certificate for limited liability companies
Description of scope of operations (for standard custom FCP applications)

Read and signed the Applicant Statement (section 8)

Completed section 5 and the section 9 (if application applies to more than one site)
Paid and provided payment details

Collection of Information

Collection of Personal Information

Pursuant to Principle 3 of the Privacy Act 2020, we advise that:
• This information is being collected for the purpose of registering under the Food Act
2014; and
• The recipient of this information, which is the agency that will collect and hold the
information, is MPI, PO Box 2526, Wellington 6140; and
• Some of the information collected will be displayed on a public register; and
• The collection of information is authorised under section 53 of the Food Act 2014. The
provision of this information is necessary in order to process an application for
registration under section 53; and
• The supply of this information is voluntary; however, failure to provide the requested
information is likely to result in a return of this application, and may ultimately result in a
refusal to register, in accordance with section 54 and 57 of the Food Act 2014; and
• Under Principles 6 and 7 of the Privacy Act 2020, you have the right of access to, and
correction of, any personal information that you have provided.

Collection of Official Information

All information provided to MPI is official information and may be subject to a request
made under the Official Information Act 1982.
If a request is made under that Act for information you have provided in this application, MPI
must consider any such request in accordance with its obligations under the Official
Information Act 1982 and any other applicable legislation.

April 2021 Page 7 of 7 FA10C: Custom Food Control Plan