Application for a Special Treatment Licence

Transcription

1 Fee Official Use Only On-line Receipt No. C&D Receipt No. Licence No. Application for a Special Treatment Licence London Local Authorities Act 1991 (part 2) Please complete this form using Black Ink and CAPITAL LETTERS For the premises detailed below, I am applying for (please tick): Grant of new licence Vary an existing licence Transfer an existing licence Change of practitioners on an existing licence Name of Premises: Licences are valid for 12 months Any special treatments that are additional to those on your current licence must be treated as a variation, and you need to tick the vary box above. An additional fee will be payable. If you are applying to transfer an existing licence into your name, please give the date of transfer in the box below. An additional fee will be payable If you are applying to change practitioners on your current licence you need to tick the box and complete the new details. An additional fee will be payable Date you would like the Special Treatments licence to start from: (new applications only): Date you wish the transfer/variation/change of practitioners to start from:

2 1. Premises where the Special Treatment(s) will be carried out: Trading Name: Full Address: Post code: Telephone No: Address: Is the premises residential Is the premises commercial What is the legal title of the applicant(s) to occupy the premises (e.g. freehold, leasehold etc?) If leasehold please give details of the name and address of the landlord 2. Details of Applicant: Mr/Mrs/Miss/Ms/other Surname: First Name(s) Full Private Address & Postcode: Telephone number: address: Date of Birth: Place of Birth:

3 3. Area of premises to be licensed (Whole/ground floor/room or area within existing premises) 4. Limited Companies: Trading Name: Registered office address Company registration number: Telephone number: address: Give names of Directors/Secretary:

4 6. Managing the Premises: Please provide details of who will be managing the premises Name: Address: Date of Birth: Telephone number: a) Has the owner of the premises or the applicant ever been refused the grant, renewal or transfer of a special treatment licence. If so by which council and what date?: b) Has the applicant(s) and/or the manager ever been issued with a Special Treatment Licence before and by which local authority: 7. Criminal Convictions Has any of the applicant(s), managers(s) or therapist(s) been convicted of a criminal offence Yes / No If Yes please give details

5 8. Details of Special Treatments and Practitioners: (massage, manicure, acupuncture, tattooing, cosmetic piercing, chiropody, light, electric, or other special treatments of a like kind or vapour, sauna, or other baths). Please list all the special treatments that you intend to provide, including any variations not included on the current licence. Any changes to practitioners must be shown. Name person carrying out the special treatment Address of person (please provide proof of address i.e. passport, driving licence) DOB Special Treatment Qualification (attach Copy to Application)

6 9. Signatures (If signing on behalf of the applicant, please state in what capacity): Date: Print Name: 10. Paying the Fee Please write the amount of the fee you are paying (The current licence fee can be found on our current fees list or by telephoning Any of the following numbers , , ) New licence (Including therapists) Variation Transfer.. Change of Practitioner By cheque: Cheques should be made payable to London Borough of Newham Cheques should be sent with your application form to the: Massage & Special Treatments Team Newham Council Town Hall Annexe 1 st Floor, Barking Road London E6 2RT Or you can pay by debit/credit card by calling us on any of the above numbers Monday to Friday 10am to 5pm.

7 11. Documentation Please enclose the following documentation with your application. The application will not be issued without them. Public liability insurance Self employed staff must also prove they have public liability insurance Fixed electrical installation certificate as required under Electricity at Work Regulations 1989 Maintenance records of portable electrical equipment Two passport-sized photographs each of applicant and operators Originals of each operator s current qualifications. (These will be returned to you) A copy of the customer health questionnaire/history card. Including aftercare advice Copies of the current treatment list and price list Fire risk assessment Scale plan of premises Please Note 1. The licence fee is non refundable. In any event you decide to withdraw your application the licence fee will be retained to cover administration costs 2. The information provided on this form may be used for the prevention and detection of fraud. Certain information may also be passed to the Inland Revenue if we are required to do so.