Isle of Wight Council

Application to vary a premises licence 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. Please Note: A Designated Premises Supervisor (DPS) Consent form must also be submitted along with this form, but only if the DPS is changing.

*

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 The Licence fee is not refundable should the application be withdrawn or refused.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)	A) For premises with no rateable value to �4,300
		B)	B) For premises with rateable value from �4,301 to �33,000
		C)	C) For premises with a rateable value of �33,001 to �87,000
		D)	D) For premises with a rateable value from �87,001 to �125,000
		E)	E) For premises with a rateable value of �125,001 and above

Your details

*	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) being the premises licence holder, apply to vary a premises licence under section 34 of the Licensing Act 2003 for the premises described in Part 1 below

Part 1 - Premises Details

*

Premises licence number

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

Please click here to read the guidance notes

Part 2 - Applicant details (Please complete this section even if the details are the same as Your Details on page 1 or Premises Details in Part 1)

	Title
	Forename
	Middle name/Initials
	Surname

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

Part 3 - Variation

*	Do you want the proposed variation to have effect as soon as possible?	Yes No
	If 'no', please give the date that you want the variation to take effect from

*	Please describe briefly the nature of the proposed variation (Please see guidance note 1)
	If your 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

Please click here to read the guidance notes

	Part 4 - Operating Schedule
	Please complete those parts of the Operating Schedule below which would be subject to change if this application to vary is successful.

	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)
	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)
	Sale by retail 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 in the column 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 films at different times from those listed in the column 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 playing 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 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 the entertainment of a similar description to that falling within (e), (f) or (g) at different times from those listed in the column 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 facilities for making music 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 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 facilities for dancing 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 entertainment of a similar description 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 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 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)

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 open to the public (If a day does not apply, please enter N/A)
	Standard days and timings (please read guidance note 6)

	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 public at different times from those listed above please list (please read guidance note 5)

Please click here to read the guidance notes

Further Information required:

*	Please identify those conditions currently imposed on the licence which you believe could be removed as a consequence of the proposed variation you are seeking
*	(i) I have enclosed the premises licence	Yes No
*	(ii) I have enclosed the relevant part of the premises licence	Yes No
	If no to both (i) and (ii) please give reasons why I have failed to enclose the premises licence or relevant part of premises licence

Please click here to read the guidance notes

Box P - Describe any additional steps you intend to take to promote the four licensing objectives as a result of the proposed variation:

	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
	Checklist	I have made or enclosed payment of the fee I have sent copies of this application and the plan to responsible authorities and others where applicable I understand that I must now advertise my application I have enclosed the premises licence 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

Please click here to read the guidance notes

	Part 5 - Signatures
	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 (the current premises licence holder) or applicant's solicitor or other duly authorised agent (please read guidance note 11). If signing on behalf of the applicant please state in what capacity.	Signed ............................................................................... Name................................................................................. Date................................................................................... Capacity.............................................................................
	Where the premises licence is jointly held signature of 2nd applicant (the current premises licence holder) 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 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