Form - Food Safety Self Inspection Form

Food Safety Self Inspection Form

Note: Questions marked by * are mandatory

Company Name

Company Address

Trading Name (if applicable)

Telephone Number

Fax Number

Email Address

How long has your company been trading at this address?

Name of Food Business Operator(s)

Please state the type of company, if relevant

Other (please state)

Total number of food handlers

Please provide the address of your Head Office if different from above

Please provide the proprietors/partners name(s)

Have you ever traded under another name or from another address

If yes, please state

	Yes	No
Do you manufacture, process or pack any food items that are sold for human consumption?	Yes	No
Do you sell food by retail?	Yes	No
Do you sell any food by wholesale?	Yes	No

Which of the following products do you use/sell?

	Yes	No
Dairy products	Yes	No
Eggs	Yes	No
Prepacked cooked meats	Yes	No
Loose cooked meats	Yes	No
Loose raw meats	Yes	No
Sandwiches prepared on the premises	Yes	No
Sandwiches brought in	Yes	No

Other (please specify)

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