Isle of Wight Council

	Application for a premises licence to be granted under the Licensing Act 2003
	Before completing this form please click here to read the guidance notes. Please Note: A Consent of Premises Licence Holder to Transfer form must also be submitted in addition to this form.

*

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. The Licence fee is not refundable should the application be withdrawn or refused. Please tick this box to confirm you have read and accept these terms and conditions

*	Band A. Band B. Band C. Band D. Band E.	A) £100.00	A) For premises with no rateable value to �4,300
		B) £190.00	B) For premises with rateable value from �4,301 to �33,000
		C) £315.00	C) For premises with a rateable value of �33,001 to �87,000
		D) £450.00	D) For premises with a rateable value from �87,001 to �125,000
		E) £635.00	E) For premises with a rateable value of �125,001 and above

Your Details

	Title
*	Forename
	Middle name/Initials
*	Surname

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

*

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

	Building name/number
	Street
	Town
	County
	Postcode
	If no postal address please provide ordnance survey map reference or description
	Telephone Number (include area code)
	Non-domestic rateable value of premises	�

Please click here to read the guidance notes

	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 b) i. a person other than an individual as a limited company b) ii. a person other than an individual as a partnership b) iii. a person other than an individual as an unincorporated association or b) iv. a person other than an individual other (for example a statutory corporation) c) a recognised club d) a charity e) the proprietor of an educational establishment f) a health service body g) an individual who is registered under Part 2 of the Care Standards Act 2000 (c14) in respect of an independent hospital h) the chief officer of police of a police force in England and Wales

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 if you are applying for the premises licence to be transfered to you as an individual or individuals. Please complete this section even if the details are the same as Your Details on Page 1. In all other cases please click here complete section B.

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

Current postal address if different from premises address:

	Building/house name/number
	Street
	Town
	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 that I am 18 years old or over (Please tick YES)

Current postal address if different from premises address

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

Please click here to read the guidance notes

	Section 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

	Forename
	Middle name/Initials
	Surname

	Building/house name/number
	Street
	Town
	County
	Postcode
	Daytime contact telephone number (include area code)
	Email address (optional)
	Fax

	Registered number (where applicable)
	Description of applicant (for example partnership, company, unincorporated association etc)

Please click here to read the guidance notes

Part 3 - Operating Schedule

*	When do you want the premises licence to start?
	If you wish the licence to be valid only for a limited period, when do you want it to end?
*	Please give a general description of the premises (please read guidance note1)
	If 5,000 or more people are expected to attend the premises at any one time, please state the number expected to attend. Please note - if your premises/event is for more than 5,000 people then there may be additional fees payable. Please contact the IW Council Licensing department for more information and to apply for these events.

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

Provision of regulated entertainment (please tick if yes)

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

Please click here to read the guidance notes

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

In all cases complete boxes N, O and P

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 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 (please read guidance note 2)	Indoors Outdoors Both
	Please give further details here (please read guidance note 3)
	State any seasonal variations for this entertainment of a similar description to that falling within (e),(f) or (g)(please read guidance note 4)
	Non-standard timings. Where you intend to use the premises for this entertainment of a similar description to that falling within (e),(f) or (g) 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 to that falling within (i) or (j) 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
	Non-standard timings. Where you intend to use the premises for the provision of late night refreshment at different times to those listed above, please list (please read guidance note 5)

Please click here to read the guidance notes

Box M - Supply of alcohol

	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)	Indoors Outdoors Both
	State any seasonal variations for the supply of 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)
	Do you intend to sell alcohol?	Yes No

State the name and details of the individual whom you wish to specify on the licence as premises supervisor

	Name
	Address (include postcode)
	Personal Licence number (if known)
	Issuing licensing authority (if known)

Please click here to read the guidance notes

Box N

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)

Box O Hours premises are open to the public - (If a day does not apply please enter N/A)

	Day	Start	Finish
*	Mon
*	Tues
*	Wed
*	Thurs
*	Fri
*	Sat
*	Sun

	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:
	Please read guidance note 9

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

Checklist

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 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

	If not submitting 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 4 - Signatures
	(please read guidance note 10)
	This form must be signed and all the relevant documents, detailed on the form, 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 along with the required documents or attend council offices after you have submitted the form online. The application fee is not refundable in the event of the application being refused or otherwise.

	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 applicant's 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)
	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