ࡱ>  bjbjVV 4<<N !!!5558m$L5}o|q|q|q|q|q|q|p*q|!i"q|v}!!!L8!o|!o|!! s ;|_|5,Owv[|}0}wv<<;|<!;| !q|q|!}< :   Application Prize Gaming Permit Licensed Premises Gaming Machine Permit Family Entertainment Centre Gaming Machine Permit Application for a permit under the Gambling Act 2005PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST If you are completing this form by hand, please write legibly in block capitals using ink. Use additional sheets if necessary. You may wish to keep a copy of the completed form for your records. Part 1 Type of permit applied for Prize Gaming ( Licensed Premises Gaming Machine Permit ( Family Entertainment Centre Gaming Machine Permit ( Do you have an existing permit to convert. Yes / No (Enclose where relevant) Do you wish to notify the Licensing Authority that you intend to provide up to a maximum of 2 gaming machines Yes / No If No how many machines are you applying for : Category of Machines Current No. Desired No. C D Total  Part 2 Applicant details If you are an individual, please fill in section A If the application is being made on behalf of an organisation (such as a company or partnership), please fill in Section B Section A Individual applicant 1. Title: Mr ( Mrs ( Miss ( Ms ( Dr ( Other (please specify) & & & & & & & & & .. 2. Surname: & & & & & & & & & & & & Other name(s): & & & & & & & & & & & & & & .. 3. Address (home or business  please specify): & & & & & & & & & & & & & & & & & & & . & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. & & & & & & & & & & & & & & & & & & .. Postcode: .. 4. Telephone number (incl. STD code): Evening: .. Daytime: .... 5. E-mail address (optional): . 6. Date of Birth (dd/mm/yyyy) : ... 7. Give details of any other licences held under the Gambling Act 2005 (Type of licence & number) : . . Section B Application on behalf of an organisation 8. Type of organisation: limited company ( partnership ( unincorporated association ( other (please specify) : & & & & & & & & & & & & & & & & & & & & & 9. Name of applicant business/organisation : & & & & & & & & & & & & & & & & & & & & & . 10. Registered address: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. .. Postcode: 11. Company registration number (if applicable) : .. 12. Give details of any other licences held under the Gambling Act 2005 (Type of licence & number ): . .. .. 13. Please state your name and position in the company: . . 14. Please give your date of birth (dd/mm/yyyy) :& & & & & & & & & & .& & & & & & & & & I confirm that I am authorised to make this application on behalf of the organisation ( (please tick)  Part 3 Premises Details If your application is in respect of premises other than a vessel, please fill in section A. If your application is in respect of a vessel, please fill in section B. Section A Premises other than a vessel 15. Proposed trading name for premises: .. 16. Address : .. . Postcode: . 17. Telephone number at premises (if known): .. 18. Scale Plan and brief description of the layout and location of the premises. (Please refer to note 1 at the end of this form for details of what should be included here. Continue on a separate page if necessary): . . . . . . 19(a) Do the premises lie within more than one licensing authority area? : ... 19(b) If the answer to 19(a) is yes, please give details of all the licensing authorities within whose area the premises are partly located, other than the licensing authority to which this application is made: .............................  Section B Vessels 20. Name of vessel to be licensed:.. (see note 2) 21. Country in which vessel is registered:.. 22(a) Place at which vessel is situated or moored for the purpose of making this application (see note 3):. . 22(b) Please confirm by ticking the relevant box whether the place stated in question 22(a) is: (i) a fixed place in or on water at which the vessel is situated; or ( (ii) a place at which the vessel is permanently moored; or ( (iii) a place at which the vessel is habitually moored; or ( (iv) in any other case, a place at which the vessel is moored or is likely to be moored or a place in the United Kingdom nearest to any place at which a vessel is, or is likely ( to be while activities are carried on in the vessel in reliance on the permit. 23. If you have ticked boxes (iii) or (iv) in your answer to question 22(b), please indicate the number of days or months in a year when you expect the vessel to be moored at the place stated in question 22(a) (see note 4): . 24. Brief description of the layout of the vessel and the location stated in question 22(a) at which it is situated or moored. (See note 1. Continue on a separate page if necessary):  Part 4 Other details about the business 25(a). Proposed hours during which facilities for gambling will be permitted: .. (if less than 24 hours, please use table below to give start time and finish time. (See Note 5) Day Start Finish Details of any seasonal variation Mon Tues Wed Thurs Fri Sat Sun 25(b). Proposed opening hours (if different) . (if less than 24 hours, please use table below to give opening and closing times) Day Opening Closing Details of any seasonal variation Mon Tues Wed Thurs Fri Sat Sun 26. Proposals for the general operation and supervision of gaming in the premises (See notes 6, 7 &8) . . . . . . . . . Part 5 Miscellaneous 27. Proposed commencement date of licence (unless this is as soon as the licence is granted): ../../(dd/mm/yyyy) 28. Contact name if you wish us to deal directly with a person other than the applicant (See Note 9): 29(a) Address for correspondence : . . Postcode: .. 29(b) If you are happy for correspondence in relation to your application to be sent via e-mail, please give the e-mail address to which you would like correspondence to be sent: . .. 30. Do you hold any other permits or premises licences that have been issued by this licensing authority? (e.g Under the Licensing Act 2003). 31. Have you ever had an application for a permit or a premises licence rejected or a permit or premises licence revoked? .(Yes / No) 32. If the answers to questions 30 or 31, above, are yes, please provide full details: .. .. .. ... .. .  Part 6 Declaration, Signatures and Checklist I confirm that, to the best of my knowledge, the information contained in this application is true. I understand that it is an offence, liable on conviction to imprisonment for a term not exceeding 51 weeks; a fine up to level 5 on the standard scale; or both, to give information which is false or misleading in, or in relation to, this application. ( I confirm that I have right to occupy the premises ( I confirm that I am aware of the mandatory conditions that will apply to this permit, should it be granted, and that my premises will be operated in accordance with those mandatory conditions, as well as any default or individual conditions that may also apply to this licence. ( If your licence application is in respect of a vessel : I confirm that I anticipate that the vessel will be situated or moored at the location I have stated in question 22(a) for a greater period of time than it will be situated or moored at any other location within the United Kingdom. ( 33. Signature of applicant or applicant s solicitor or other duly authorised agent (see note 10). If signing on behalf of an applicant, please state capacity: Signature: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. Print Name: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Date: & & & & & & & & & & & & & & & & Capacity: & & & & & & & & & & & & & & & & . 34. Checklist: I have made/enclosed payment of the correct fee. ( I have enclosed the existing Permit for conversion ( I have enclosed a plan of the premises marked up accordingly. ( I have enclosed all appropriate documentation (Policies, Statements, ( Insurance, CRB Disclosures).  I understand that if I do not comply with the above requirements, my ( application may be rejected. I understand that I must now advertise this application and give ( correct notice to responsible authorities.  Part 7  Guidance notes 1. The description of the premises must include the following information: Where the premises is a building, or part of a building (this is likely to exclude tracks and vessels), whether the whole building is subject to the permit, or only part of it (with a description of the uses to which the rest of the building is put), the nature of the building (e.g. whether it is detached, multi-level, part of a shopping centre or service station etc). Where the premises are a vessel, whether the permit will extend to the entire vessel, or only part of it (with a description of the uses to which the rest of the vessel will be put), the nature of the vessel (size, capacity, type of vessel etc). Applications must be accompanied by a scale plan of the premises showing : the extent of the boundary or perimeter of the premises or part of the premises the location of any external or internal walls the position of each point of entry to and exit from the premises the location of any bars and the location of category C and D gaming machines. the type and location of any other machines for example skills with prizes machines or amusement only machines to be provided. identify the location and use of any other areas of the premises accessible by the public which are used for the purposes of the provision of gaming or any other purpose. The nature of the area in which the premises are located, or in the case of a vessel, the nature of the area in which the vessel is situated or moored for the purposes of this application (e.g. primarily residential, for business or retail use etc). The name or nature of any immediate neighbours. Immediate neighbours means, in relation to premises that are in a building or on a track, those on either side of the premises; those opposite any entrance or exit to the premises; and where the premises are part of a multi-level building, those above and below the premises. In the case of vessels, it means the nature of vessels that are or are likely to be, moored next to the vessel in respect of which the application is made, and/or the nature of and premises directly adjacent to the place where the vessel is moored or situated. The nature of the street on which any entrance or exit to the premises is located. This information should describe whether the street is pedestrianised, is a main road, a cul-de-sac, a side road etc. This information is not required for vessels. Access to the premises in particular give details of any direct access that will be permitted from other types of premises with details of the nature of that other type of premises. This information is required for vessels. Whether the premises have already been constructed and are ready for occupation/operation as gambling premises. If the answer to this is no, please give details of the nature of the work still to be done to the premises before it will be suitable for occupation/operation. This information is required for vessels. The current use of the premises. This information is required for vessels. 2. The name of the vessel is the name with which it is registered with the relevant maritime authority. For the purposes of this application form, any subsequent reference to a premises is a reference to the vessel in respect of which the application is made, not the place at which it is situated or moored. 3. The place stated in answer to this question must be one of the following: a fixed place in or on water at which the vessel is situated; a place at which the vessel is permanently moored; a place at which the vessel is habitually moored; in any other case, a place at which the vessel is moored or is likely to be moored, or a place in the United Kingdom nearest to any place at which a vessel is, or is likely to be while activities are carried on in the vessel in reliance on the permit. You will be asked to confirm which one of these applies in question 22(b). 4. This information is needed to ensure that the application has been made to the correct authority. The application should be made to the authority in whose area it is anticipated that the vessel will be situated or moored for the greatest proportion of time. You will be asked to confirm that you have specified this place at the end of the form. 5. If using the table, please use the 24 hour clock. 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For example evidence of a policy that all persons employed in the centre have been subject to an Enhanced Criminal Record Bureau Disclosure which reveals no relevant offences or that in the absence of such checks that unaccompanied children will not be admitted. discourage or exclude children during school times. discourage or exclude vulnerable persons. ensure that all persons engaged in the operation of the premises are / will be suitably trained. A Licenced Premises Gaming Machine Permit you must attach Evidence of suitable public liability insurance. A statement explaining the safeguards and procedures you have in place and produce copies of any policies referred to therein : for the admittance of children to and supervision of children whilst in the premises. to check that persons using gaming machines are 18 or over, for example by supporting a proof of age scheme requiring the production of photographic identification, preferably a challenge 21 scheme. to discourage or exclude vulnerable persons. A Prize Gaming Permit you must attach Evidence of suitable public liability insurance. A statement clarifying your knowledge and experience of the legal requirements relevant to the application. Where the application is made by an individual(s) an enhanced Criminal Record Bureau Disclosure obtained within the last 6 months must be provided in respect of each individual. A statement explaining the safeguards and procedures you have in place and produce copies of any policies referred to therein : to ensure the safety and protection of children admitted to the premises. For example evidence of a policy that all persons employed in the centre have been subject to an Enhanced Criminal Record Bureau Disclosure which reveals no relevant offences or that in the absence of such checks that unaccompanied children will not be admitted. to discourage or exclude children during school times. to discourage or exclude vulnerable persons. to ensure that all persons engaged in the operation of the premises are / will be suitably trained. 7. If your application is in respect of premises comprising part of a track, please give details of how bet receipt terminals on the premises will be supervised at any time during which children or young persons have access to the premises. Note that it is a mandatory condition that bet receipt terminals are supervised and you are advised to familiarise yourself with the mandatory supervision requirements before filling in this section. If your application is in respect of any other types of premises, you may write not applicable here. 8. If this is an application in relation to a track, and there is already a premises licence which has effect in relation to that track (the main premises licence), this permit application must be accompanied by an application under section 187 to vary the main premises licence so that the main premises licence will not have effect in relation to the area covered by this application. 9. If a name and address is given here, it will be the one used in all correspondence. Otherwise it will be the name and address given in part 2 of the application. 10. The applicants agent may sign the form if they have actual authority to do so. Electronic signatures may be used.       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