Application for a premises licence to be granted

under the Licensing Act 2003

PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST

Before completing this form please read the guidance notes at the end of the form. If you are completing this form by hand please write legibly in block capitals. In all cases ensure that your answers are inside the boxes and written in black ink. Use additional sheets if necessary.

You may wish to keep a copy of the completed form for your records.

I/We
(Insert name(s) of applicant)

apply for a premises licence under section 17 of the Licensing Act 2003 for the premises described in Part 1 below (the premises) and I/we are making this application to you as the relevant licensing authority in accordance with section 12 of the Licensing Act 2003

Part 1 – Premises details

Postal address of premises or, if none, ordnance survey map reference or description

Post town	Postcode

Telephone number at premises (if any)
Non-domestic rateable value of premises	£

Part 2 - Applicant details

Please state whether you are applying for a premises licence as	Please tick as appropriate

a)	an individual or individuals *
please complete section (A)
b)	a person other than an individual *
i	as a limited company/limited liability partnership
please complete section (B)
ii	as a partnership (other than limited liability)
please complete section (B)
iii	as an unincorporated association or
please complete section (B)
iv	other (for example a statutory corporation)
please complete section (B)
c)	a recognised club
please complete section (B)
d)	a charity
please complete section (B)
e)	the proprietor of an educational establishment
please complete section (B)
f)	a health service body
please complete section (B)
g)

ga)

a person who is registered under Part 2 of the Care Standards Act 2000 (c14) in respect of an independent hospital in Wales

a person who is registered under Chapter 2 of Part 1 of the Health and Social Care Act 2008 (within the meaning of that Part) in an independent hospital in England

please complete section (B)

please complete section (B)
h)	the chief officer of police of a police force in England and Wales
please complete section (B)

* If you are applying as a person described in (a) or (b) please confirm (by ticking yes to one box below):
I am carrying on or proposing to carry on a business which involves the use of the premises for licensable activities; or
I am making the application pursuant to a
statutory function or
a function discharged by virtue of Her Majesty’s prerogative

(A) INDIVIDUAL APPLICANTS (fill in as applicable)

Mr

Mrs

Miss

Ms

Other Title (for example, Rev)

Surname

First names

Date of birth I am 18 years old or over
Please tick yes
Nationality
Current residential address if different from premises address
Post town	Postcode
Daytime contact telephone number
E-mail address (optional)

SECOND INDIVIDUAL APPLICANT (if applicable)

Mr

Mrs

Miss

Ms

Other Title (for example, Rev)

Surname

First names

Date of birth I am 18 years old or over
Please tick yes
Nationality
Current postal address if different from premises address
Post town	Postcode
Daytime contact telephone number
E-mail address (optional)

(B) OTHER APPLICANTS

Please provide name and registered address of applicant in full. Where appropriate please give any registered number. In the case of a partnership or other joint venture (other than a body corporate), please give the name and address of each party concerned.

Name

Address

Registered number (where applicable)

Description of applicant (for example, partnership, company, unincorporated association etc.)

Telephone number (if any)

E-mail address (optional)

Part 3 Operating Schedule

When do you want the premises licence to start?	DD

MM

YYYY

If you wish the licence to be valid only for a limited period, when do you want it to end?	DD

MM

YYYY

Please give a general description of the premises (please read guidance note 1)

If 5,000 or more people are expected to attend the premises at any one time, please state the number expected to attend.

What licensable activities do you intend to carry on from the premises?

(please see sections 1 and 14 and Schedules 1 and 2 to the Licensing Act 2003)

Provision of regulated entertainment (please read guidance note 2)	Please tick all that apply
a)	plays (if ticking yes, fill in box A)
b)	films (if ticking yes, fill in box B)
c)	indoor sporting events (if ticking yes, fill in box C)
d)	boxing or wrestling entertainment (if ticking yes, fill in box D)
e)	live music (if ticking yes, fill in box E)
f)	recorded music (if ticking yes, fill in box F)
g)	performances of dance (if ticking yes, fill in box G)
h)	anything of a similar description to that falling within (e), (f) or (g)

(if ticking yes, fill in box H)
Provision of late night refreshment (if ticking yes, fill in box I)
Supply of alcohol (if ticking yes, fill in box J)
In all cases complete boxes K, L and M

A

Plays

Standard days and timings (please read guidance note 7)	Will the performance of a play take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for performing plays (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the performance of plays at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

B

Films

Standard days and timings (please read guidance note 7)	Will the exhibition of films take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for the exhibition of films (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the exhibition of films at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

C

Indoor sporting events

Standard days and timings (please read guidance note 7)	Please give further details (please read guidance note 4)

Day	Start	Finish
Mon
Tue	State any seasonal variations for indoor sporting events (please read guidance note 5)

Wed
Thur	Non standard timings. Where you intend to use the premises for indoor sporting events at different times to those listed in the column on the left, please list (please read guidance note 6)

Fri
Sat
Sun

D

Boxing or wrestling entertainments

Standard days and timings (please read guidance note 7)	Will the boxing or wrestling entertainment take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for boxing or wrestling entertainment (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for boxing or wrestling entertainment at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

E

Live music

Standard days and timings (please read guidance note 7)	Will the performance of live music take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for the performance of live music (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the performance of live music at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

F

Recorded music

Standard days and timings (please read guidance note 7)	Will the playing of recorded music take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for the playing of recorded music (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the playing of recorded music at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

G

Performances of dance

Standard days and timings (please read guidance note 7)	Will the performance of dance take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for the performance of dance (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the performance of dance at different times to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

H

Anything of a similar description to that falling within (e), (f) or (g)

Standard days and timings (please read guidance note 7)	Please give a description of the type of entertainment you will be providing

Day	Start	Finish	Will this entertainment take place indoors or outdoors or both – please tick (please read guidance note 3)	Indoors
Mon
Outdoors
Both
Tue	Please give further details here (please read guidance note 4)

Wed
Thur	State any seasonal variations for entertainment of a similar description to that falling within (e), (f) or (g) (please read guidance note 5)

Fri
Sat	Non standard timings. Where you intend to use the premises for the entertainment of a similar description to that falling within (e), (f) or (g) at different times to those listed in the column on the left, please list (please read guidance note 6)

Sun

I

Late night refreshment

Standard days and timings (please read guidance note 7)	Will the provision of late night refreshment take place indoors or outdoors or both – please tick (please read guidance note 3)

Indoors
Outdoors
Day	Start	Finish
Both
Mon	Please give further details here (please read guidance note 4)

Tue
Wed	State any seasonal variations for the provision of late night refreshment (please read guidance note 5)

Thur
Fri	Non standard timings. Where you intend to use the premises for the provision of late night refreshment at different times, to those listed in the column on the left, please list (please read guidance note 6)

Sat
Sun

J

Supply of alcohol

Standard days and timings (please read guidance note 7)	Will the supply of alcohol be for consumption – please tick (please read guidance note 8)

On the premises
Off the premises
Day	Start	Finish
Both
Mon	State any seasonal variations for the supply of alcohol (please read guidance note 5)

Tue
Wed
Thur	Non standard timings. Where you intend to use the premises for the supply of alcohol at different times to those listed in the column on the left, please list (please read guidance note 6)

Fri
Sat
Sun

State the name and details of the individual whom you wish to specify on the licence as designated premises supervisor (Please see declaration about the entitlement to work in the checklist at the end of the form):

Name

Date of birth

Address

Postcode
Personal licence number (if known)

Issuing licensing authority (if known)

K

Please highlight any adult entertainment or services, activities, other entertainment or matters ancillary to the use of the premises that may give rise to concern in respect of children (please read guidance note 9).

L

Hours premises are open to the public

Standard days and timings (please read guidance note 7)	State any seasonal variations (please read guidance note 5)

Day	Start	Finish
Mon
Tue
Wed
Non standard timings. Where you intend the premises to be open to the public at different times from those listed in the column on the left, please list (please read guidance note 6)

Thur
Fri
Sat
Sun

M Describe the steps you intend to take to promote the four licensing objectives:

a) General – all four licensing objectives (b, c, d and e) (please read guidance note 10)

b) The prevention of crime and disorder

c) Public safety

d) The prevention of public nuisance

e) The protection of children from harm

Checklist:

Please tick to indicate agreement

I have made or enclosed payment of the fee.

I have enclosed the plan of the premises.
I have sent copies of this application and the plan to responsible authorities and others where applicable.
I have enclosed the consent form completed by the individual I wish to be designated premises supervisor, if applicable.
I understand that I must now advertise my application.

I understand that if I do not comply with the above requirements my application will be rejected.

[Applicable to all individual applicants, including those in a partnership which is not a limited liability partnership, but not companies or limited liability partnerships] I have included documents demonstrating my entitlement to work in the United Kingdom (please read note 15).

IT IS AN OFFENCE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION. THOSE WHO MAKE A FALSE STATEMENT MAY BE LIABLE ON SUMMARY CONVICTION TO A FINE OF ANY AMOUNT.

IT IS AN OFFENCE UNDER SECTION 24B OF THE IMMIGRATION ACT 1971 FOR A PERSON TO WORK WHEN THEY KNOW, OR HAVE REASONABLE CAUSE TO BELIEVE, THAT THEY ARE DISQUALIFIED FROM DOING SO BY REASON OF THEIR IMMIGRATION STATUS. THOSE WHO EMPLOY AN ADULT WITHOUT LEAVE OR WHO IS SUBJECT TO CONDITIONS AS TO EMPLOYMENT WILL BE LIABLE TO A CIVIL PENALTY UNDER SECTION 15 OF THE IMMIGRATION, ASYLUM AND NATIONALITY ACT 2006 AND PURSUANT TO SECTION 21 OF THE SAME ACT, WILL BE COMMITTING AN OFFENCE WHERE THEY DO SO IN THE KNOWLEDGE, OR WITH REASONABLE CAUSE TO BELIEVE, THAT THE EMPLOYEE IS DISQUALIFIED.

Part 4 – Signatures (please read guidance note 11)

Signature of applicant or applicant’s solicitor or other duly authorised agent (see guidance note 12). If signing on behalf of the applicant, please state in what capacity.

Declaration	[Applicable to individual applicants only, including those in a partnership which is not a limited liability partnership] I understand I am not entitled to be issued with a licence if I do not have the entitlement to live and work in the UK (or if I am subject to a condition preventing me from doing work relating to the carrying on of a licensable activity) and that my licence will become invalid if I cease to be entitled to live and work in the UK (please read guidance note 15).

The DPS named in this application form is entitled to work in the UK (and is not subject to conditions preventing him or her from doing work relating to a licesable activity) and I have seen a copy of his or her proof of entitlement to work, if appropriate (please see note 15)

Signature
Date
Capacity

For joint applications, signature of 2nd applicant or 2nd applicant’s solicitor or other authorised agent (please read guidance note 13). If signing on behalf of the applicant, please state in what capacity.

Signature
Date
Capacity

Contact name (where not previously given) and postal address for correspondence associated with this application (please read guidance note 14)

Post town	Postcode
Telephone number (if any)
If you would prefer us to correspond with you by e-mail, your e-mail address (optional)

Notes for Guidance

Describe the premises, for example the type of premises, its general situation and layout and any other information which could be relevant to the licensing objectives. Where your application includes off-supplies of alcohol and you intend to provide a place for consumption of these off-supplies, you must include a description of where the place will be and its proximity to the premises.

In terms of specific regulated entertainments please note that:

Plays: no licence is required for performances between 08:00 and 23.00 on any day, provided that the audience does not exceed 500.

Films: no licence is required for ‘not-for-profit’ film exhibition held in community premises between 08.00 and 23.00 on any day provided that the audience does not exceed 500 and the organiser (a) gets consent to the screening from a person who is responsible for the premises; and (b) ensures that each such screening abides by age classification ratings.

Indoor sporting events: no licence is required for performances between 08.00 and 23.00 on any day, provided that the audience does not exceed 1000.

Boxing or Wrestling Entertainment: no licence is required for a contest, exhibition or display of Greco-Roman wrestling, or freestyle wrestling between 08.00 and 23.00 on any day, provided that the audience does not exceed 1000. Combined fighting sports – defined as a contest, exhibition or display which combines boxing or wrestling with one or more martial arts – are licensable as a boxing or wrestling entertainment rather than an indoor sporting event.

Live music: no licence permission is required for:

a performance of unamplified live music between 08.00 and 23.00 on any day, on any premises.

a performance of amplified live music between 08.00 and 23.00 on any day on premises authorised to sell alcohol for consumption on those premises, provided that the audience does not exceed 500.

a performance of amplified live music between 08.00 and 23.00 on any day, in a workplace that is not licensed to sell alcohol on those premises, provided that the audience does not exceed 500.

a performance of amplified live music between 08.00 and 23.00 on any day, in a church hall, village hall, community hall, or other similar community premises, that is not licensed by a premises licence to sell alcohol, provided that (a) the audience does not exceed 500, and (b) the organiser gets consent for the performance from a person who is responsible for the premises.

a performance of amplified live music between 08.00 and 23.00 on any day, at the non-residential premises of (i) a local authority, or (ii) a school, or (iii) a hospital, provided that (a) the audience does not exceed 500, and (b) the organiser gets consent for the performance on the relevant premises from: (i) the local authority concerned, or (ii) the school or (iii) the health care provider for the hospital.

Recorded Music: no licence permission is required for:

any playing of recorded music between 08.00 and 23.00 on any day on premises authorised to sell alcohol for consumption on those premises, provided that the audience does not exceed 500.

any playing of recorded music between 08.00 and 23.00 on any day, in a church hall, village hall, community hall, or other similar community premises, that is not licensed by a premises licence to sell alcohol, provided that (a) the audience does not exceed 500, and (b) the organiser gets consent for the performance from a person who is responsible for the premises.

any playing of recorded music between 08.00 and 23.00 on any day, at the non-residential premises of (i) a local authority, or (ii) a school, or (iii) a hospital, provided that (a) the audience does not exceed 500, and (b) the organiser gets consent for the performance on the relevant premises from: (i) the local authority concerned, or (ii) the school proprietor or (iii) the health care provider for the hospital.

Dance: no licence is required for performances between 08.00 and 23.00 on any day, provided that the audience does not exceed 500. However, a performance which amounts to adult entertainment remains licensable.

Cross activity exemptions: no licence is required between 08.00 and 23.00 on any day, with no limit on audience size for:

any entertainment taking place on the premises of the local authority where the entertainment is provided by or on behalf of the local authority;

any entertainment taking place on the hospital premises of the health care provider where the entertainment is provided by or on behalf of the health care provider;

any entertainment taking place on the premises of the school where the entertainment is provided by or on behalf of the school proprietor; and

any entertainment (excluding films and a boxing or wrestling entertainment) taking place at a travelling circus, provided that (a) it takes place within a moveable structure that accommodates the audience, and (b) that the travelling circus has not been located on the same site for more than 28 consecutive days.

Where taking place in a building or other structure please tick as appropriate (indoors may include a tent).

For example the type of activity to be authorised, if not already stated, and give relevant further details, for example (but not exclusively) whether or not music will be amplified or unamplified.

For example (but not exclusively), where the activity will occur on additional days during the summer months.

For example (but not exclusively), where you wish the activity to go on longer on a particular day e.g. Christmas Eve.

Please give timings in 24 hour clock (e.g. 16.00) and only give details for the days of the week when you intend the premises to be used for the activity.

If you wish people to be able to consume alcohol on the premises, please tick ‘on the premises’. If you wish people to be able to purchase alcohol to consume away from the premises, please tick ‘off the premises’. If you wish people to be able to do both, please tick ‘both’.

Please give information about anything intended to occur at the premises or ancillary to the use of the premises which may give rise to concern in respect of children, regardless of whether you intend children to have access to the premises, for example (but not exclusively) nudity or semi-nudity, films for restricted age groups or the presence of gaming machines.

Please list here steps you will take to promote all four licensing objectives together.

The application form must be signed.

An applicant’s agent (for example solicitor) may sign the form on their behalf provided that they have actual authority to do so.

Where there is more than one applicant, each of the applicants or their respective agent must sign the application form.

This is the address which we shall use to correspond with you about this application.

15.	Entitlement to work/immigration status for individual applicants and applications from partnerships which are not limited liability partnerships:

A licence may not be held by an individual or an individual in a partnership who is resident in the UK who:

does not have the right to live and work in the UK; or

is subject to a condition preventing him or her from doing work relating to the carrying on of a licensable activity.

Any premises licence issued in respect of an application made on or after 6 April 2017 will become invalid if the holder ceases to be entitled to work in the UK.

Applicants must demonstrate that they have an entitlement to work in the UK and are not subject to a condition preventing them from doing work relating to the carrying on of a licensable activity. They do this by providing with this application copies or scanned copies of the following documents (which do not need to be certified).

Documents which demonstrate entitlement to work in the UK

An expired or current passport showing the holder, or a person named in the passport as the child of the holder, is a British citizen or a citizen of the UK and Colonies having the right of abode in the UK [please see note below about which sections of the passport to copy].

An expired or current passport or national identity card showing the holder, or a person named in the passport as the child of the holder, is a national of a European Economic Area country or Switzerland.

A Registration Certificate or document certifying permanent residence issued by the Home Office to a national of a European Economic Area country or Switzerland.

A Permanent Residence Card issued by the Home Office to the family member of a national of a European Economic Area country or Switzerland.

A current Biometric Immigration Document (Biometric Residence Permit) issued by the Home Office to the holder indicating that the person named is allowed to stay indefinitely in the UK, or has no time limit on their stay in the UK.

A current passport endorsed to show that the holder is exempt from immigration control, is allowed to stay indefinitely in the UK, has the right of abode in the UK, or has no time limit on their stay in the UK.

A current Immigration Status Document issued by the Home Office to the holder with an endorsement indicating that the named person is allowed to stay indefinitely in the UK or has no time limit on their stay in the UK, when produced in combination with an official document giving the person’s permanent National Insurance number and their name issued by a Government agency or a previous employer.

A full birth or adoption certificate issued in the UK which includes the name(s) of at least one of the holder’s parents or adoptive parents, when produced in combination with an official document giving the person’s permanent National Insurance number and their name issued by a Government agency or a previous employer.

A birth or adoption certificate issued in the Channel Islands, the Isle of Man or Ireland when produced in combination with an official document giving the person’s permanent National Insurance number and their name issued by a Government agency or a previous employer.

A certificate of registration or naturalisation as a British citizen, when produced in combination with an official document giving the person’s permanent National Insurance number and their name issued by a Government agency or a previous employer.

A current passport endorsed to show that the holder is allowed to stay in the UK and is currently allowed to work and is not subject to a condition preventing the holder from doing work relating to the carrying on of a licensable activity.

A current Biometric Immigration Document (Biometric Residence Permit) issued by the Home Office to the holder which indicates that the named person can currently stay in the UK and is allowed to work relation to the carrying on of a licensable activity.

A current Residence Card issued by the Home Office to a person who is not a national of a European Economic Area state or Switzerland but who is a family member of such a national or who has derivative rights or residence.

A current Immigration Status Document containing a photograph issued by the Home Office to the holder with an endorsement indicating that the named person may stay in the UK, and is allowed to work and is not subject to a condition preventing the holder from doing work relating to the carrying on of a licensable activity when produced in combination with an official document giving the person’s permanent National Insurance number and their name issued by a Government agency or a previous employer.

A Certificate of Application, less than 6 months old, issued by the Home Office under regulation 17(3) or 18A (2) of the Immigration (European Economic Area) Regulations 2006, to a person who is not a national of a European Economic Area state or Switzerland but who is a family member of such a national or who has derivative rights of residence.

Reasonable evidence that the person has an outstanding application to vary their permission to be in the UK with the Home Office such as the Home Office acknowledgement letter or proof of postage evidence, or reasonable evidence that the person has an appeal or administrative review pending on an immigration decision, such as an appeal or administrative review reference number.

Reasonable evidence that a person who is not a national of a European Economic Area state or Switzerland but who is a family member of such a national or who has derivative rights of residence in exercising treaty rights in the UK including:-

evidence of the applicant’s own identity – such as a passport,

evidence of their relationship with the European Economic Area family member – e.g. a marriage certificate, civil partnership certificate or birth certificate, and

evidence that the European Economic Area national has a right of permanent residence in the UK or is one of the following if they have been in the UK for more than 3 months:

(i)	working e.g. employment contract, wage slips, letter from the employer,

(ii)	self-employed e.g. contracts, invoices, or audited accounts with a bank,

(iii)	studying e.g. letter from the school, college or university and evidence of sufficient funds; or

(iv)	self-sufficient e.g. bank statements.

Family members of European Economic Area nationals who are studying or financially independent must also provide evidence that the European Economic Area national and any family members hold comprehensive sickness insurance in the UK. This can include a private medical insurance policy, an EHIC card or an S1, S2 or S3 form.

Original documents must not be sent to licensing authorities. If the document copied is a passport, a copy of the following pages should be provided:-

(i) any page containing the holder’s personal details including nationality;

(ii) any page containing the holder’s photograph;

(iii) any page containing the holder’s signature;

(iv) any page containing the date of expiry; and

(v) any page containing information indicating the holder has permission to enter or remain in the UK and is permitted to work.

If the document is not a passport, a copy of the whole document should be provided.

Your right to work will be checked as part of your licensing application and this could involve us checking your immigration status with the Home Office. We may otherwise share information with the Home Office. Your licence application will not be determined until you have complied with this guidance.

Sam Hardy

2017-03-22

emmal.thompson

Fujitsu Services