Application TO VARYor change details relating to a SPECIAL treatmentPremises 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

Premises Licence Details

1 / 1.1 / Existing Licence Number:*
1.2 / Expiry Date:*
1.3 / Premises Name:*
1.4 / Premises Address:*
1.5 / Postcode:*
1.6 / Premises Telephone Number:
1.7 / Website Address:
1.8 / Email address:

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

Yes
No(If no got to Section 3)

Agent Details

2 / 2.1 / Agent name:*
2.2 / Agent Address:*
2.3 / Postcode:
2.4 / Agent Telephone Number:*
2.5 / Agent Email:

Individual Licensee Details (if licensee is a company please complete part 4 below)

3 (a) / 3.1 / First name(s):*
3.2 / Surname:*
3.3 / Home address:*
3.4 / Postcode:*
3.5 / Email address:
3.6 / Contact telephone number: (if different from premises)

Additional Licensee Details

3 (b) / 3.7 / First name(s):*
3.8 / Surname:*
3.9 / Home Address:*
3.10 / Postcode:*
3.11 / Email address:
3.12 / Contact telephone number: (if different from premises)

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

4 / 4.1 / Business Name:* (if your business is registered, use its registered name)
4.2 / Is your business registered in the UK with Companies House?* / Yes □
No □
4.3 / Registered Number: (* if you completed field 4.2 above)
4.4 / VAT Number: (put “None” if you are not registered for VAT)
4.5 / Legal Status: (e.g. Company Partnership etc. If you are a Sole Trader complete individual licensee details
4.6 / For the person completing this form on behalf of the company, your position in the business:* (e.g Owner, Manager, Director, etc)
4.7 / Home Country: (The Country where the headquarters of your business is located)
4.8 / Registered Address:
4.9 / Postcode:
4.10 / Directors, Partners, Owners and Managers
4.11 / 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.
4.12 / Are there any such people for whom you need to provide details? / Yes □
No □

Variation Proposals*

5 / 5.1 / Please tick one or more of the following variations:
Change the layout of the premises / □(please complete 6.1)
Add one or more treatments to the licence / □(please complete 6.2)
Remove one or more treatments from the licence / □(please complete 6.2)
Vary the conditions of the licence (including standard conditions) / □(please complete 6.3)
Change of details (e.g. change of trading as name, change of address for licensee, change of licensee name due to marriage (not a transfer to another person) / □(please complete 6.4)
6 / 6.1 / Please provide a description of the works intended to be made at the premises: Please note that any change to the layout of the premises requires new plans to be submitted.
6.2 / Please tickthe treatment/s you wish to add or remove :*
Lower Risk Treatments
ADD REMOVE ADD REMOVE ADD REMOVE
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)
ADD REMOVE ADD REMOVE ADD REMOVE
1 / Acupuncture / 2 / Body Piercing / 3 / Intense Pulse Light
4 / Laser / 5 / Micropigmintation / 6 / Tattooing
7 / Ear Piercing / 8 / Electrolysis / 9 / Chiropody (Podiatry)
10 / U V Tanning
6.3 / Please state the condition number you wish to vary and also give your reasons for the request (if you run out of space please provide information on a separate sheet). If you wish to amend the wording of a condition or add a condition then please provide the wording of the condition with the reasons for the change or addition of that condition:
Condition No: / Reasons and wording of condition (if applicable):
Condition No: / Reasons and wording of condition (if applicable):
Condition No: / Reasons and wording of condition (if applicable):
6.4 / Please provide details of the changes that need to be made to the Council’s records:
7. Licence Fees
Application to vary the special treatment premises licence.
Note: Applications to vary the licence are required for the following changes to the licence:
  • Change the layout of the premises (amend the current deposited plan),
  • Add/amend or remove a condition or conditions (excluding changing the number of therapists or removing permitted special treatment(s).
  • Add one or more special treatments to the licence.
/ £535
Application for a variation to the special treatment premises licence to:
  • Change of details (e.g. change of trading as name, change of address for licensee, change of licensee name due to marriage (not a transfer to another person)
/ £104
Duplicate Licence / £18

Attachments*:

Fee (cheque/postal order etc)
Plans (if changing layout of the premises)

Declaration:

  • A copy of this application has been sent to the Metropolitan Police Service and the London Fire and Emergency Planning Authority.
  • (for Limited companies only) There have been no changes in the Directors of the company since the grant of the current licence (if changes have taken place, please submit written details, see part 4 above).
  • 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.

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

For joint applications signature of 2nd applicant or 2nd 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.