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Application to vary a club premises certificate to be granted under the Licensing Act 2003

Isle of Wight Council

	Application to vary a club premises certificate to be granted under the Licensing Act 2003
	Environmental Health Isle of Wight Council Jubilee Stores The Quay Newport Isle of Wight PO30 2EH

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

The giving of false information may result in the certificate 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The fee is not refundable should the application be withdrawn or refused.

Please tick this box to confirm you have read and accept the terms and conditions

Band A.

Band B.

Band C.

Band D.

Band E.

A) T£100.00

A) For premises with no rateable value to �4,300

B) T£190.00

B) For premises with rateable value from �4,301 to �33,000

C) T£315.00

C) For premises with a rateable value of �33,001 to �87,000

D) T£450.00

D) For premises with a rateable value from �87,001 to �125,000

E) T£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
*	Telephone number (include area code)
*	Email address
	Fax

(Insert name of club) applies for a club premises certificate under section 84 of the Licensing Act 2003 for the premises named in Part 1 below.

Part 1 - Club Premises Details

Club premises certificate number

*	Name of Club
	Building name/number
	Street
	Town
	County
	Postcode
	If no postal address, please provide an Ordnance survey map reference or description
	Telephone number (if any)
	E-mail address (optional)
*	Name of person performing duties of a secretary to the club

Address of person performing duties of a secretary to the club:

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

	Daytime contact telephone number (if any)
	E-mail address (optional)

Part 2 - Applicant details (Please complete this part even if details are the same as Your Details Page 1)

	Title
*	Forename
*	Surname

	Daytime contact telephone number (if any)
	E-mail address (optional)

Current postal address if different from premises address:

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

Part 3 - Variation

Do you want the proposed variation to have effect as soon as possible?

Yes

If 'no', when do you want the variation to take effect from?

(dd/mm/yyyy)

Please describe briefly the nature of the proposed variation

(Please see guidance note 1)

If the club's proposed variation would mean that 5,000 or more people are expected to attend the premises at any one time, please state the number expected to attend

	Part 4 - Club Operating Schedule
	Please complete those parts of the Club Operating Schedule which would be subject to change if this application to vary is successful. What qualifying club activities do you intend to conduct on the club premises which will be affected by your application?

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)

Note: If you have ticked any of the check boxes above, please ensure that the corresponding section is also completed below

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)

The supply of alcohol by or on behalf of a club to, or to the order of, a member of the club

(if ticking yes, you must complete box L)

The sale by retail of alcohol by or on behalf of a club to a guest of a member of the club for consumption on the premises where the sale takes place

(if ticking yes, you must complete box L)

In all cases complete boxes M, N, O and P

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the performance of a play at different times from those listed above, please list (please read guidance note 5)

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the exhibition of film at different times from those listed above, please list (please read guidance note 5)

	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 the club intends to use the premises for indoor sporting events at different times from those listed above, please list (please read guidance note 5)

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the boxing or wrestling entertainment at different times from those listed above, please list (please read guidance note 5)

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the performance of live music at different times from those listed above, please list (please read guidance note 5)

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the performance of recorded music at different times from those listed above, please list (please read guidance note 5)

	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

You must tick at least one of these boxes

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 the club intends to use the premises for the performance of dance at different times from those listed above, please list (please read guidance note 5)

	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 that the club will be providing

Will this entertainment take place indoors or outdoors or both ? please tick (please read guidance note 2)

Indoors

Outdoors

Both

You must tick at least one of these boxes

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 the club intends to use the premises for this entertainment at different times from those listed above, please list (please read guidance note 5)

	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 the club 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

You must tick at least one of these boxes

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 the club intends 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)

	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

Please give a description of the type of facilities for dancing that the club will be providing

Will the facilities for dancing be indoors or outdoors or both - please tick (see guidance note 2)

Indoors

Outdoors

Both

You must tick at least one of these boxes

Please give further details here (please read guidance note 3)

State any seasonal variations for the provision of dancing facilities (please read guidance note 4)

Non-standard timings. Where the club intends to use the premises for the provision of dancing facilities at different times from those listed above, please list (please read guidance note 5)

	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 the club will be providing

Will the entertainment facility be indoors or outdoors or both - please tick (please read guidance note 2)

Indoors

Outdoors

Both

You must tick at least one of these boxes

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 the club intends 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)

	Box L - 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)

Indoors

Outdoors

Both

You must tick at least one of these boxes

State any seasonal variations (please read guidance note 4)

Non-standard timings. Where the club intends to use the premises for the supply of alcohol at different times from those listed above, please list (please read guidance note 5)

Box M - Hours club premises are open to the members and guests (if any 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)

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)

Further Information Required:

Please identify those conditions currently imposed on the certificate which you believe could be removed as a consequence of the proposed variation you are seeking

If you have not ticked one of these boxes please fill in reasons for not including the certificate, or part of it below

I have made or enclosed payment of the fee

I will give a copy of this application to the chief officer of police

I have enclosed the consent form completed by the proposed premises supervisor

I have enclosed the premises licence, or relevant part of it or explanation

I will give a copy of this form to the existing premises supervisor, if any

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

Reasons why the club has failed to enclose the club premises certificate or relevant part of it

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

*	General ? all four licensing objectives (b,c,d,e) (please read guidance note 9)
*	The prevention of crime and disorder
*	Public safety
*	The prevention of public nuisance
*	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 sent copies of this application and the plan to responsible authorities

I understand that I must now advertise my application

I have enclosed the club premises certificate or relevant part of it or explanation

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 ALL THE RELEVANT DOCUMENTS, DETAILED ON THE FORM, SUBMITTED TO THE LICENSING SECTION BEFORE THE APPLICATION CAN BE PROCESSED. 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 withdrawn.

I (Insert full name) make this application on behalf of the club and have authority to bind the club

Signature

Signed ...............................................................................

Name.................................................................................

Date...................................................................................

Capacity.............................................................................

Is there an alternative address that you would prefer us to use for correspondence associated with this application? (please read guidance note 11)

*Yes

*If 'yes' please provide address details here:

	Building/house name/number
	Street address
	Town name
	County
	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

Product	Cost	VAT code	GL Code
Band A licence fee	£100.00	AN	67605732501
Band B licence fee	£190.00	AN	67605732501
Band C licence fee	£315.00	AN	67605732501
Band D licence fee	£450.00	AN	67605732501
Band E licence fee	£635.00	AN	67605732501

Date printed: 07/03/2013