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					      APPLICATION FOR A NEW SPECIAL TREATMENT PREMISES
                           LICENCE
                              IMPORTANT: This form is open to inspection by the public.

* Indicates that this field is mandatory and must be completed. If a mandatory field is not completed then
the application will be classed as invalid until such time as either that information is supplied or the
authority determine to cease processing the application and return the whole application as invalid

Are you an agent acting on behalf of the applicant?*

Yes
No (If no got to Section 3)

Agent Details

1     1.1       Agent name:*
      1.2       Agent Address:*



      1.3       Postcode:
      1.4       Agent Telephone Number:*
      1.5       Agent Email:



Individual Licensee Details (if licensee is a company please complete part 3 below)
2     2.1       First name(s):*
(a)   2.2       Surname:*
      2.3       Home address:*


      2.4       Postcode:*
      2.5       Email address:
      2.6       Contact telephone number:
                (if different from premises)

      2.7       Date of Birth*
      2.8       Place of Birth*

Additional Licensee Details
2     2.9       First name(s):*
(b)
      2.10      Surname:*
      2.11      Home Address:*


      2.12      Postcode:*
      2.13      Email address:
    2.14   Contact telephone number:
           (if different from premises)

    2.15   Date of Birth*
    2.16   Place of Birht*
If there are more than 2 licensees please attach an additional sheet with this application
form detailing the first name, surname and their home address for each individual
licensee.

Company Details


3   3.1    Business Name:* (if your business
           is registered, use its registered name)




                                                           □
    3.2    Is your business registered in
           the UK with Companies
           House?*                        Yes


                                                     No    □
    3.3    Registered Number: (* if you
           completed field 4.2 above)
    3.4    VAT Number: (put “None” if you are
           not registered for VAT)
    3.5    Legal Status: (e.g. Company
           Partnership, Sole Trader,
           etc)
    3.6    For the person completing
           this form on behalf of the
           company, your position in the
           business:* (e.g Owner,
           Manager, Director, etc)
    3.7    Home Country: (The Country where
           the headquarters of your business is
           located)




    3.8    Registered Address:



    3.9    Postcode:


    3.10   Directors, Partners, Owners and Managers

    3.11   You must provide details of all COMPANY DIRECTORS and the SECRETARY (if
           the applicant is a company), all PARTNERS (if it is a partnership), OFFICE
           BEARERS (if it is a club or association), all OWNERS of the business or premises
           and all MANAGERS of the business or organisation, including day-to-day
           MANAGERS OF THE PREMISES.



                                                           □
    3.12   Are there any such people
           for whom you need to
           provide details?                          Yes
                                            No        □
Other Business Interests

    3.12
           Is the applicant, or any person named in this application, involved in any way with
           any other similar establishment?


           Yes         □
           No          □
           Please provide details, including the name and address of the establishment and
           the nature and extent of the interest. (If more than one establishment please
           provide a separate sheet).




Premises Details

4   4.1    Premises Name:*
    4.2    Premises Address:*




    4.3    Postcode:*
    4.4    Premises Telephone
           Number:
    4.5    Website Address:
    4.6    Email address:
    4.7    The maximum number of therapists providing treatments
           on the premises at any one time:* (please be aware that
           this number will be conditioned on the licence. If you wish
           to add more therapists after this licence is granted a
           variation application is required.)

Details of Premises

    4.8
           Describe:

                   The premises, giving details of treatment rooms. Other rooms used for the
                    business and the facilities provided
     4.9             Provision for cleaning the premises, fittings and equipment and sterilization
                      of instruments




     4.10            Provision for disposal of waste, used materials, needles, etc




Opening Times


5    5.1      State proposed opening times for each day of the week:




Special Treatments Provided at the Premises

6    Please tick each of the special treatments that will be provided at the premises:*

                                                Lower Risk Treatments
                                 (Tick
                                 below)

 1   Reflexology                          2    Infra Red                               3    Sauna & Steam
 4   Aromatherapy                         5    High Frequency                          6    Shiatsu
 7   Manicure                             8    Flotation Tank                          9    Massage
10   Colour Therapy                       11   Lymphatic Drainage                     12    Spa & Bath
13   Micro Current Therapy                14   Pedicure                               15    Ultra Sound
16   Facial                               17   Faradism                               18    Nail Extensions



                                               Higher Risk Treatments
                (please note that if you tick one or more of this list you will be required to pay the higher fee)
                                 (Tick
                                 below)

 1   Acupuncture                          2    Body Piercing                           3    Intense Pulse Light
 4   Laser                                5    Micropigmintation                       6    Tattooing
 7   Ear Piercing                         8    Electrolysis                            9    Chiropody (Podiatry)
10   Ultra Violet Tanning


Please indicate whether you provide treatments to:*
Women Only
Men Only
Both sexes,
separate sessions
Both sexes, mixed
sessions
Previous Applications

7       7.1
               Have you, or any person named in or associated with this application, previously
               applied for a similar licence? (tick all that apply)

                      No                                               Yes – application granted and revoked


                      Yes – application granted                        Yes – application refused

               If yes please provide details:




Convictions

8       8.1    Have you, or any person named in or associated with this application, been
               convicted of any crime or offence?


               Yes          □       if yes please provide details on a separate sheet



               No           □
Additional Details

9       9.1    Provide any additional information which is required or relevant to your application
               (check the Council’s Rules of Procedure).




Attachments:

Fee (cheque/postal order etc)

Declaration:

         A copy of this application has been sent to the Metropolitan Police Service and the London Fire and
          Emergency Planning Authority.
         I am aware of the regulations of the authority concerning special treatments. The details contained in the
          application form and any attached documentation are correct to the best of my knowledge and belief.
         The only persons I will employ to provide special treatments will be those registered by the Council as a
          therapist (practitioner) and I will permit them only to give those treatments specified on their identification
          card and registration document.
Ticking this box indicates you have read and understood the above declaration

Signature of applicant or applicant’s solicitor or other duly authorised agent. If signing on behalf of the
applicant please state in what capacity.


Signature

Date

Capacity


                                        nd                 nd
For joint applications signature of 2 applicant or 2 applicant’s solicitor or other authorised agent. If
signing on behalf of the applicant please state in what capacity.

Signature

Date

Capacity



 Contact name (where not previously given) and postal address for correspondence associated
                     with this application (please read guidance note 13)




  Post town                                                         Post code
    Telephone number (if any)
If you would prefer us to correspond with you by e-mail your e-mail address (optional)




                                                   Premises Management,
                  Licensing Service, 4th Floor, Westminster City Hall, 64 Victoria Street, London. SW1E 6QP
                             Telephone number: 020 7641 8549, Facsimile number: 020 7641 7815.

				
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posted:9/29/2012
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