London Borough of Hounslow

Transcription

1 Ld Brugh f Huslw Applicati fr a premises licece t be grated uder the Licesig Act 2003 PLEASE READ THE FOLLOWIG ISTRUCTIOS FIRST Befre cmpletig this frm please read the guidace tes at the ed f the frm. lf yu are cmpletig this frm by had please write legibly i blck capitals. I all cases esure that yur aswers are iside the bxes ad writte i black ik. Use additial sheets if ecessary. Yu may wish t keep a cpy fthe cmpleted frm fr yur recrds. l/we Sim Haabuss (lseft ame(s) f applicat) apply fr a premises licece uder secti 17 f the Licesig Act 2003 fr the premises described i Part 1 belw (the premises) ad l/we are makig this applicati t yu as the relevat licesig authrity i accrdace with secti 12 f the Licesig Act 2003 Part 1 - Premises Details ame ad pstal address f premises r, if e, rdace survey map referece r descripti Access Self Sage 30 Rugby Rad Pst tw Twickeham Pst cde TW1 1DG Telephe umber at premises (if ay) dmestic rateable value f premises 698 ll 12 mee sq x e58 Part 2 - Applicat Details Please state whether yu are applyig fr a premises licece as Please tick ves a) a idividual r idividuals * b) a pers ther tha a idividual * i. as a limited cmpay ii. as a partership iii. as a uicrprated assciati r iv. ther (fr example a statuy crprati) g please cmplete secti (A) please cmplete secti (B) please cmplete secti (B) please cmplete secti (B) please cmplete secti (B)

2 c) a recgised club d) a charity e) the prprie f a educatial establishmet f) a health service bdy S) a pers wh is registered uder Part 2 f the Care Stadards Act 2000 (c14) i respect f a idepedet hspital h) the chief fficer f plice f a plice frce i Eglad ad Wales please cmplete secti (B) please cmplete secti (B) please cmplete secti (B) please cmplete secti (B) please cmplete secti (B) please cmplete secti (B) * lf yu are applyig as a pers described i (a) r (b) please cfirm: Please tick yes. I am carryig r prpsig t carry a busiess which ivlves the use f the premises fr licesable activities; r a. I am makig the applicati pursuat t a statuy fucti r fr a fucti discharged by virtue f Her Majesty's prergative u1t (A) IDIVIDUAL APPLICATS (fill i as applicable) Mr Mrs Miss! Ms Surame First ames Other Title (fr example, Rev) I am 18 years ld r ver! Please tick yes Curret pstal address if differet frm premises address Pst Tw Daytime ctactelephe umber address (ptial) Pstcde

3 SECOD IDIVIDUAL APPLICAT (if applicable) Mr Mrs Miss Ms Surame First ames Other Title (fr example, Rev) I am 18 years ld r ver Please tick yes Curret pstal address if differet frm premises address Pst Tw Daytime ctactelephe umber address (ptial) Pstcde (B) OTHER APPLTCATS Please prvide ame ad registered address f applicat i full. Where apprpriate please give ay registered umber. I the case fa partership r therjit veture (ther tha a bdy crprate), please give the ame ad address f each party ccered, ame Mr Tipple Limited / Sim Haabuss Address 40a Sidey Rad Twickeham TW1 1JR Registered umber (where applicable) Descripti f applicat (fr example, partership, cmpay, uicrprated assciati etc.) Limited Telephe umber (if ay) O77BO address (ptial) sim@mrtipple.cm

4 Part 3 Operatig Schedule Whe d yu wat the premises licece t start? lf yu wish the licece t be valid ly fr a limited perid, whe d vu wat it t ed? Please give a geeral descripti f the premises (please read guidace tel) Access Self Sage ctais bth dmestic ad cmmercial ad dmestic sage slutis. The rm that will be used fr purely fr the mail rder ad pstal disibuti f bttled beer ad cider is 125 sq ft, all rders will be purely made ad paid fr ver the iteret. The rm is reted is purely a sage uit fr bttles f beer ad alchl. lf 5,000 r mre peple are expected t atted the premises at ay e time. lease state the umber exected t atted. /A What licesable activities d yu ited t carry frm the premises? (Pfease see sectis 1 ad 14 f the Licesig Act 2003 ad Schedules 1 ad 2 t the Licesig Act 2003) Prvisi f requlated etertaimet a) plays (if tickig yes, fill i bx A) b) films (if tickig yes, fill i bx B) c) idr sprtig evets (if tickig yes, fill i bx C) d) bxig r wrestlig etertaimet (if tickig yes, fill i bx D) e) live music (if tickig yes, fill i bx E) D recrded music (if tickig yes, fill i bx F) S) perfrmaces f dace (if tickig yes, fill i bx G) h\ aythig f a similar descripti t that fallig withi (e),(0 r (g) (if tickig yes, fill i bx H) Please tick yes!

5 Prvisi f etertaimet facilities: i) makig music (if tickig yes, fill i bx l) j) dacig (if tickig yes, fill i bx J) r,\ ^'' etertaimet f a similar descripti t that fallig withi (i) r (j) (if tickig yes, fill i bx K1 Prvisi f late iht refreshmet (if tickig yes, fill i bx L) Suplv f alchl (if tickig yes, fill i bx M) I all cases cmplete bxes, O ad P! Z

6 M Supply f alchl Will the supplv f alchl be fr O the Stadard days ad csumpti (Please tick bxl (please read premises timigs (please read guidace te 7) guidace te 6) Off the Mr Tipple is purely a e-cmmerce mail premrses V Day Start Fiish rder busiess Bth M 08:00 22:00 State av seasal variatis fr the supplv f alchl (please read guidace te 4) Tue 08:00 22:00 There will be seasal variati, peratis will be cstat thrughut the year. Wed 08:00 22:OO Thur Fri Sat 08:00 22:OO stadard timiqs. Where vu ited t use the premises fr the supplv f alchl at differetimes t thse listed i the clum the left. please list (please read guidace te 5) 08:00 22:OO The timigs f warehuse perati purely exist fr the packagig ad pstig f bxes f bttled beer ad cider t custmers via mail rder. Su State the ame ad details f the idividual whm yu wish t specify the licece as premise supervisr ame Address Sim Haabuss 40a Sidey Rad Twickeham Midd lesex Pstcde I TW1 1JR Persal Licece umber (if kw) Awaitig Licece frm Richmd cucil lssuig licesig authrity (if kw) Ld Brugh f Richmd up Thames 18

7 P Describe the steps yu ited t take t prmte the fur licesig bjectives: a) Geeral - all fur licesig bjectives (b,c,d,e) (please read guidace te 9) Geerally due t the ature f the busiess beig purely mail rder all fur licesig bjectives will be very secure, there will be ctact the premises with custmers ad alchl. b) The preveti f crime ad disrder Apart frm makig sure the sage uit is prperly lcked ad secure, agai because custmers are Dreset the Dremises crime ad disrder situatis will be zet. c) Public safety Public safety will ever affected due t the public ever havig access t the sage uit. d) The preveti f public uisace Public uisace w't be a prblem because the sage uit is't pe t the public. e) The prtecti f childre frm harm Childre will be ever allwed access t the sage uit, the sage uit will t be pe t the public. 20

8 Please highlight ay adult etertaimet r services, activities, ther etertaimet r matters acillary t the use f the premises that may give rise t ccer i respect f childre (please read guidace te 8) /A Hurs prem ises are pe t the public Stadardays ad timigs (please read guidace te 6) Day Start Fiish M State av seasal variatis (please read guidace te 4) The premise will t pe t the public. Tue Wed Thur Fri stadard e i fhe [hlic al differet times frm lhse listed i the clum the left. please list (please read guidace te 5) The premise will t pe t the public. Sat Su 19

9 Please tick yes. I have made r eclsed paymet f the fee. I have eclsed the la fthe remises. I have set cpies f this applicati ad the pla t respsible authrities ad thers where applicable. I have eclsed the cset frm cmpleted by the idividual I wish t be premises supervisr, if applicable. I uderstad that I must w advertise my applicati. I uderstad that if I d t cmply with the abve requiremets my applicati will be rejected IT IS A OFFECE, LIABLE O COVICTIO TO A FIE UP TO LEVEL 5 O THE STADARD SCALE, UDER SECTIO 158 OF THE LICESIG ACT 2OO3 TO MAKE A FALSE STATEMET I OR I COECTIO WITH THIS APPLICATIO Part 4 - Sigatures (please read guidace te 10) Sigature f applicat r applicat'slici r ther duly authrised aget (See guidace te 11). lf sigig behalf f the applicat please state i what capacity. a E r V Frjit applicatisigature f 2d applicat r 2"d applicat' slici r ther authrised aget. (please read guidace te 12). lf sigig behalf f the applicat please state i what capacity. Sigature Date Capacity Ctact ame (where t previusly give) ad pstal address fr crrespdece assciated with this applicati (please read guidace te 13) Pst tw Pst cde Telephe umber (if ay) lf yu wuld prefer us t crrespd with yu by yur address (ptial) 21

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