Isle of Wight Council

	Application for a provisional statement to be granted under the Licensing Act 2003
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

	Before completing this form please click here to read the guidance notes. Please click here to view the fee structure under the Licensing Act 2003. You may wish to keep a copy of the completed form for your records.
*	The giving of false information may result in registration being refused or revoked, and the local authority reserve the right to make such further enquiries arising out of this application as they may consider desirable. This licence fee is not refundable in the event of the application being refused or otherwise. Please tick this box to confirm you have read and accept these terms and conditions
	The Licence fee of £315.00will be required when submitting this application.

Your Details

	Title
*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town name
	County
*	Postcode
	Telephone number (include area code)
	Email address
	Fax

Please click here  to read the guidance notes.

*

I/We (Insert name(s) of applicant) apply for a provisional statement under section 29 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

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	If no postal address please provide ordnance survey map reference or description
	Telephone number at premises (if any)
	Non-domestic rateable value of premises	�

	Part 2 - Applicant details
	If yes to (a) please complete section A, for all other answers please complete section B.

*

Please state whether you are applying for a premises licence as

a) an individual or individuals (PLEASE COMPLETE SECTION A) b) i. a person other than an individual as a limited company (PLEASE COMPLETE SECTION B) b) ii. a person other than an individual as a partnership (PLEASE COMPLETE SECTION B)  b) iii. a person other than an individual as an unincorporated association or (PLEASE COMPLETE SECTION B) b) iv. a person other than an individual 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) an individual who is registered under Part 2 of the Care Standards Act 2000 (c14) in respect of an independent hospital (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:

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 I am making the application persuant to a function discharged by virtue of Her Majestys prerogative

Please click here  to read the guidance notes.

	Section A - INDIVIDUAL APPLICANTS (Please complete this section even if the details are the same as Your Details page 1)
	Please complete this section if you are applying for the premises licence to be transfered to you as an individual or individuals. In all other cases please click here complete section B.

	Title
	Forename
	Middle name/Initials
	Surname
	I confirm I am 18 years old or over (Please tick YES)

Current postal address if different from premises address

	Building/house name/number
	Street address
	Town name
	County
	Postcode

	Daytime contact telephone number (include area code)
	Email address
	Fax

Please click here  to read the guidance notes.

Second individual applicant (if applicable)

	Title
	Forename
	Middle name/Initials
	Surname
	I confirm I am 18 years old or over Please tick if YES

Current postal address if different from premises address (please include post town and postcode)

	Building/house name/number
	Street address
	Town name
	County
	Postcode

	Daytime contact telephone number (include area code)
	Email address
	Fax

Please click here  to read the guidance notes.

	Section B - Other Applicants (if b) to h) mandatory)
	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

	Forename
	Middle name/Initials
	Surname

	Building/house name/number
	Street address
	Town name
	County
	Postcode
	Tel number (include area code)
	Email address
	Fax

	Registered number (where applicable)
	Description of applicant (for example partnership, company, unincorporated association etc)
	What is the nature of your interest in the premises?

Please click here  to read the guidance notes.

Part 3 - Schedule of works

	Is the premises?	about to be constructed being extended or altered
	Please give details of the work and please attach plans of the work being done or about to be done at the premises
	Please give particulars of the premises to which the application relates (please read guidance note 1)

Which licensable activities will the premises be used for?

Provision of regulated entertainment (please tick if yes)

a) plays (If yes, fill in box A) b) films (If yes, fill in box B) c) indoor sporting events (If yes, fill in box C) d) boxing or wrestling entertainment (If yes, fill in box D) e) live music (If yes, fill in box E) f) recorded music (If yes, fill in box F) g) performances of dance (If yes, fill in box G) h) anything of a similar description to that falling within (e), (f) or (g) (If yes, fill in box H)

Please click here  to read the guidance notes.

	Provision of entertainment facilities	i) making music (If yes, fill in box I) j) dancing (If yes, fill in box J) k) entertainment of a similar description to that falling within (i) or (j) (If yes, fill in box K)
	Provision of late night refreshment	(If yes, fill in box L)
	Supply of alcohol	(If yes, fill in box M)

Complete boxes M, N, O and P

	Section 4
	Filling in this section is optional, if you want to continue straight to the end of the form, please click here.

General description of premises (please read guidance note1)

Please click here  to read the guidance notes.

	Box A - Plays
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the performance of a play take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for performing plays (please read guidance note 4)
	Non standard timings. Where you intend to use the premises for the performance of plays at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box B - Films
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the exhibition of films take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the exhibition of films (please read guidance note 4)
	Non standard timings. Where you intend to use the premises for the exhibition of film at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box C - Indoor sporting events
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Please give further details here (please read guidance note 3)
	State any seasonal variations for indoor sporting events (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for indoor sporting events at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box D - Boxing or wrestling entertainments
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the boxing or wrestling entertainment take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for boxing or wrestling entertainment (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the boxing or wrestling entertainment at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box E - Live music
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the performance of live music take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the performance of live music (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the performance of live music at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box F - Recorded music
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the playing of recorded music take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the playing of recorded music (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the performance of recorded music at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box G - Performances of dance
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the performance of dance take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the performance of dance (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the performance of dance at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box H - Anything of a similar description to that falling within (e), (f) or (g)
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Please give a description of the type of entertainment you will be providing
	Will this entertainment take place indoors or outdoors or both - please tick	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for this entertainment (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for this entertainment at different times from those listed above, please list (please read guidance note 5)

Please click here  to read the guidance notes.

	Box I - Provision of facilities for making music
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Please give a description of the type of facilities for making music that you will be providing
	Will the facilities for making music be indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the provision of facilities for making music (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the provision of facilities for making music at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box J - Provision of facilities for dancing
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the facilities for dancing be indoors or outdoors or both - please tick (see guidance note 2)	Indoors Outdoors Both
	Please give a description of the facilities for dancing you will be providing
	Please give further details here (please read guidance note 3)
	State any seasonal variations for providing dancing facilities (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the provision of dancing facilities at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box K - Provision of facilities for entertainment of a similar description to that falling within (i) or (j)
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Please give a description of the type of entertainment facility you will be providing
	Will the entertainment facility be indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the provision of facilities for entertainment of a similar description to that falling within (i) or (j) (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the provision of facilities for this entertainment at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box L - Late night refreshment
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the provision of late night refreshment take place indoors or outdoors or both - please tick (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for the provision of late night refreshment (please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for the provision of late night refreshment at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box M - Supply of alcohol
	Standard days and timings (please read guidance note 6)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

	Will the supply of alcohol be for consumption (Please tick box) (please read guidance note 7)	On the premises Off the premises Both
	State any seasonal variations for the supply og alcohol (please read guidance note 4)
	Non standard timings. Where you intend to use the premises for the supply of alcohol at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

	Box O - Hours premises are open to the public
	Standard days and timings (please read guidance note 6)

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 8)

	Day	Start	Finish
	Mon
	Tues
	Wed
	Thurs
	Fri
	Sat
	Sun

Box N

	State any seasonal variations (please read guidance note 4)
	Non standard timings. Where you intend the premises to be open to the members and guests at different times from those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes.

Box P - Describe the steps you intend to take to promote the four licensing objectives:

	a) General - all four licensing objectives (b,c,d,e) (please read guidance note 9)
	b) The prevention of crime and disorder
	c) Public safety
	d) The prevention of public nuisance
	e) The protection of children from harm

Please click here to read the guidance notes.

Checklist

I have made or enclosed payment of the fee. I have enclosed the plans of the works to be done at the premises I have sent copies of this application and the plan to responsible authorities 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

	If not submitting this form online, please make your cheque payable to Isle of Wight Council.
	IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE, UNDER SECTION 158 OF THE LICENSING ACT 2003 TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION

	Part 5 - Signatures
	(please read guidance note 10)
	This form must be signed and presented to the licensing section before a decision is made and the licence may be granted. Either print off the completed form, sign and post to the licensing department or attend council offices to sign after you have submitted the form online.

	Signature of applicant or applicant's solicitor or other duly authorised agent (See guidance note 11). If signing on behalf of the applicant please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity.............................................................................
	For joint applications signature of 2nd applicant or 2nd applicants solicitor or other authorised agent. (please read guidance note 12). If signing on behalf of the applicant please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity.............................................................................

*	Contact name and postal address for correspondence associated with this application (please read guidance note 13)
	Post Town
	Postcode
	Telephone number (if any)
	If you would prefer us to correspond with you by e-mail your e-mail address (optional)

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box