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Application for a Sex Establishment Licence to be
Granted/Renewed/Varied
Local Government (Miscellaneous Provisions Act 1982, Sec 2 Sch 3
As amended by the Policing and Crime Act 2009, Sec 27, Sch 3 and Sch 7 para 3.
PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST
Before completing this form please read the guidance notes at the end of the form. If you are completing this form by hand please write legibly in block capitals. In all cases ensure that your answers are inside the boxes and written in black ink. Use additional sheets of paper if necessary. You may wish to keep a copy of the completed form for your records.
I/We.........................................................................................................................................................apply for
(Please ")
T h e g r a n t o f a S e x E s t a b l i s h m e n t L i c e n c e f o r t h e p r e m i s e s ;
T h e r e n e w a l o f a S e x E s t a b l i s h m e n t L i c e n c e f o r t h e p r e m i s e s ;
T h e V a r i a t i o n o f a S e x E s t a b l i s h m e n t L i c e n c e f o r t h e p r e m i s e s ;
T h e T r a n s f e r o f a o f a S e x E s t a b l i s h m e n t L i c e n c e f o r t h e p r e m i s e s ;
N a t u r e o f L i c e n c e . ( P l e a s e ")
S e x S h o p S e x C i n e m a S e x u a l E n t e r t a i n m e n t V e n u e
S t a t e w h e t h e r t h e a p p l i c a t i o n i s i n r e s p e c t o f ( p l e a s e ")
P r e m i s e s V e s s e l V e h i c le Stall
If the premise is a vehicle, vessel or stall, please state the exact location where the vehicle, vessel or stall will be sited?
ordnance survey map reference or description:
Part 1 Premises details.
Postal address of premises:
Postal town:
Postal code:
Page 1 of 13
Telephone number(s) at premises:
Daytime:
Evening:
Mobile:
Please provide a copy of a plan of the premises at least to scale 1:100.
If you intend to only use part of the premises, please indicate on the above plan by marking an outline of the area with a red line, the area you intend to use as a sex establishment.
If you do not intend to use the whole of the premises as a sex establishment, please state to what purpose the remainder if the premises will be used:
If you do not intend to use the whole of the premises, please provide the name(s) of those person(s) responsible for the management of the remaining parts of the premises:
Name
Name
Name
Part 2 Applicants Details.
Please state whether you are applying for a licence as
An individual please complete Section (A)
A person other than an individual
as a limited company please complete section (B)
as a partnership please complete section (B)
as an unincorporated association please complete section (B)
other (for example a statutory corporation) please complete section (B)
SECTION A FOR INDIVIDUAL APPLICANTS ONLY
Your personal detailsTITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)
Surname:
Forename(s):
PREVIOUS NAMES (if applicable) please enter details of any previous names or maiden names. Please continue on a separate sheet if necessary.TITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)
Surname:
Forename(s):
Page 2 of 13
Part 2 Applicants Details Continued.
I am 18 years old or over. (please tick) " Y e s N o D a t e o f b i r t h : P l a c e o f b i r t h : N a t i o n a l i n s u r a n c e N o : P a s s p o r t D e t a i l s :
( i s s u e d b y , v a l i d i t y d a t e s ) A D D R E S S W H E R E O R D I N A R I L Y R E S I D E N T ( P l e a s e p r o v i d e f u l l d e t a i l s o f a l l a d d r e s s e s w h e r e o r d i n a r i l y r e s i d e n t d u r i n g t h e p a s t 5 y e a r s ) : 1 .
P o s t Town:Post Code:From:To:2.
Post Town:Post Code:From:To:3.
Post Town:Post Code:From:To:TELEPHONE NUMBERSDaytime:Evening:Mobile:FAX Number:Email Address:
Details of Convictions First Applicant (if applicable)
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
SECOND INDIVIDUAL APPLICANT (if applicable)
Your personal detailsTITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)Surname:
Forename(s):PREVIOUS NAMES (if applicable) please enter details of any previous names or maiden names. Please continue on a separate sheet if necessary.TITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)Surname:
Forename(s):
Page 3 of 13
SECOND INDIVIDUAL APPLICANT (if applicable)Continued.
Details of Convictions Second Applicant (if applicable)
I am 18 years o l d o r o v e r . ( p l e a s e t i c k ) " Y e s N o D a t e o f b i r t h : P l a c e o f b i r t h : N a t i o n a l i n s u r a n c e N o : P a s s p o r t D e t a i l s :
( i s s u e d b y , v a l i d i t y d a t e s ) A D D R E S S W H E R E O R D I N A R I L Y R E S I D E N T ( P l e a s e p r o v i d e f u l l d e t a i l s o f a l l a d d r e s s e s w h e r e o r d i n a r i l y r e s i d e n t d u r i n g the past 5 years):1.
Post Town:Post Code:From:To:2.
Post Town:Post Code:From:To:3.
Post Town:Post Code:From:To:TELEPHONE NUMBERSDaytime:Evening:Mobile:FAX Number:Email Address:
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
Page 4 of 13
SECTION B (FOR ALL OTHER TYPES OF APPLICANT)
Please provide the name and registered address of applicant in full. Where appropriate please give any registered number. In the case of a partnership or other joint venture (other than a body corporate), please give the name and address of each party concerned. Full details of all directors/partners must be given.
Name:
Registered Office/Address for service of Notice:
Company Registered Number (where applicable):
Description of applicant (for example partnership. Company, unincorporated association etc):
Telephone number:
Email address:
Details of all Directors/Partners
Name (including any forenames)AddressNationalityDate of BirthCapacity (Director/Partner/Secretary etc)
Details of Convictions Other types of applicant (if applicable)
Do you have or any of the above have convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
Name....................................YES/NO If yes, please provide details:
Name....................................YES/NO If yes, please provide details:
Name.....................................YES/NO If yes, please provide details:
Name.....................................YES/NO If yes, please provide details:
Page 5 of 13
(please continue on separate pages if necessary)
Name of offenderCourt CodeDate of ConvictionOffence CodeFine or Other
Sentence
Part 3 Management of Premises and Detail of Operation
Who will be responsible for the day to day management of the premises? Please provide details of all managerial and supervisory staff involved in the running of the premises. Further sheets are available.
Managers personal detailsTITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)Surname:
Forename(s):PREVIOUS NAMES (if applicable) please enter details of any previous names or maiden names. Please continue on a separate sheet if necessary.TITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state) S u r n a m e :
F o r e n a m e ( s ) : I a m 1 8 y e a r s o l d o r o v e r . ( p l e a s e t i c k ) " Y e s N o D a t e o f b i r t h : P l a c e o f b i r t h : N a t i o n a l i n s u r a n c e N o : P a s s p o r t D e t a i l s :
( i s s u e d b y , v a l i d i t y d a t e s ) A D D R E S S W H E R E O R D I N A R I L Y R E S I D E N T ( P l e a s e p r o v i d e f u l l d e t a i l s o f a l l a d d r esses where ordinarily resident during the past 5 years):1.
Post Town:Post Code:From:To:2.
Post Town:Post Code:From:To:3.
Post Town:Post Code:From:To:TELEPHONE NUMBERSDaytime:Evening:Mobile:FAX Number:Email Address:
Page 6 of 13
Details of Convictions - Manager
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
Supervisors personal detailsTITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)Surname:
Forename(s):
PREVIOUS NAMES (if applicable) please enter details of any previous names or maiden names. Please continue on a separate sheet if necessary.TITLE (delete as appropriate): Mr / Mrs / Ms / Other (please state)Surname:
Forename(s):I am 18 years old or over. (please tick) " Y e s N o D a t e o f b i r t h : P l a c e o f b i r t h : N a t i o n a l i n s u r a n c e N o : P a s s p o r t D e t a i l s :
( i s s u e d b y , v a l i d i t y d a t e s ) A D D R E S S W H E R E O R D I N A R I L Y R E S I D E N T ( P l e a s e p r o v i d e f u l l d e t a i l s o f a l l a d d r e s s e s w h e r e o r d i n a r i l y r e s i d e n t d u r i n g t h e p a s t 5 y e a r s ) : 1 .
P o st Town:Post Code:From:To:2.
Post Town:Post Code:From:To:3.
Post Town:Post Code:From:To:TELEPHONE NUMBERSDaytime:Evening:Mobile:FAX Number:Email Address:
Page 7 of 13
Details of Convictions - Supervisor
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
Particulars of other Managers/Supervisory Staff
Name:
Address:
Date of Birth:Place of Birth:National Insurance Number:Passport Details:Telephone NumbersEmail address
Details of Convictions - Other Manager/Supervisor
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
Name:
Address:
Date of Birth:Place of Birth:National Insurance Number:Passport Details:Telephone NumbersEmail address
Page 8 of 13
Details of Convictions Other Manager/Supervisor
Do you have any convictions not yet spent under the terms of the Rehabilitation of Offenders Act 1974?
YES/NO If yes, please provide details:
Court CodeDate of ConvictionOffence CodeFine or Other
SentenceComments
Part 4 Operating Details
When do you want the licence to start?If you wish the licence to be valid only for a limited period, when do you want the licence to end?
Hours Premises are open to the public : (please use 24 hour clock)
StartFinishMondayTuesdayWednesdayThursdayFridaySaturdaySunday
What activities/entertainment(s) will take place at the premises
Please give a general description of the premises, including the following information;
Management structure:
Experience of running similar establishments (full details to be provided):
Page 9 of 13
Details of welfare provisions for performers :
(please attach any conditions imposed within the performers engagement contract)
How do you intend to address the conditions in 鶹Ƶs Policy for Sex Establishments:
The Councils standard conditions will automatically be attached to the licence. Do you wish to propose any additional conditions which would give assurances to the public that the premises will be operated responsibly?
Additional conditions:
Page 10 of 13
Part 5 -Notices
Please give details of all (including the size) of all advertisements or signs on or in the premises which may be visible from public areas:
Under what name will the premises operate?
Please describe the intended colour and decor for the interior and exterior of the premises:
What steps do you intend to take to ensure that passersby are unable to view articles or activities?
Part 6 Previous Licence
Have any of the applicants or others persons who will be associated with the operation of the premises previously held a licence for a Sex Establishment?
YES/NO
If yes, please provide details below.
Page 11 of 13
Have any of the applicants ore others associated with the applicants ever been refused a licence for a Sex Establishment?
YES/NO
If yes, please provide details below.
Part 7 Checklist
I have; ( p l e a s e t i c k ) " E n c l o s e d t w o p h o t o g r a p h s o f m y s e l f ( a n d f o r p e r s o n w h o s e d e t a i l s h a v e b e e n i n c l u d e d i n t h i s a p p l i c a t i o n ) o n e o f w h i c h i s e n d o r s e d a s a t r u e l i k e n e s s b y a s o l i c i t o r o r n o t a r y ( p erson of standing in the community or any individual with a professional qualification).
Enclose a plan/set of plans to scale 1:100.
Sent (or will send a copy of this application to the Chief Officer Northumbria Police, South Tyneside Area Command, Secretan Way, South Shields, Tyne and Wear, NE33 1RR.I enclose a certified copy of the passport document of each of the applicants/managers and supervisors referred to in this application.Enclosed the payment for the application.
Part 8 Declarations
Declaration of first individual applicant
The information contained in this form is correct to the best of my knowledge and belief.
I understand that it is an offence to knowingly or recklessly make a false statement in connection with an application for the grant, renewal or variation of a Sex Establishment Licence. (A person is to be treated as making a false statement if he/she produces, furnishes signs or otherwise makes use of a document that contains a false statement). To do so could result in prosecution and a fine not exceeding [20000.SIGNATURE:
DATE:
Declaration of second individual applicant
The information contained in this form is correct to the best of my knowledge and belief.
I understand that it is an offence to knowingly or recklessly make a false statement in connection with an application for the grant, renewal or variation of a Sex Establishment Licence. (A person is to be treated as making a false statement if he/she produces, furnishes signs or otherwise makes use of a document that contains a false statement). To do so could result in prosecution and a fine not exceeding [20000]. SIGNATURE:
DATE:
Page 12 of 13
Or Declaration of person on behalf of other type of applicant
The information contained in this form is correct to the best of my knowledge and belief.
I understand that it is an offence to knowingly or recklessly make a false statement in connection with an application for the grant, renewal or variation of a Sex Establishment
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DATE:
(Position within the company)
Data Protection
鶹Ƶ is responsible for protecting the public funds it administers. To do this we may use the information you give us on this form or that is held about you to detect and prevent crime or fraud. We may also share this information with other bodies that audit and administer public funds.
For the purposes of the Data Protection Act 1998, 鶹Ƶ is the Data Controller (the holder, user and processor) of the information. We will keep all information safe and secure.
If you would like to know more about what information we hold about you, or the way we use your information please contact the Licensing Team on 0191 4247695 or if you wish to make a subject access request then please write to the Records Management Team at the following address: Records Management Team, Town Hall & Civic Offices, Westoe Road, South Shields, Tyne and Wear. NE33 2RL.
Please return this form to;
The Licensing Section
鶹Ƶ
Housing Strategy and Regulatory Services
Town Hall and Civic Offices
Westoe Road
South Shields
Tyne and Wear
NE33 2RL
Enquiries should be directed to the Licensing Section
Tel 0191 4247695
HYPERLINK "mailto:licensing@southtyneside.gov.uk" licensing@southtyneside.gov.uk
Further information can be found at
HYPERLINK "http://www.southtyneside.info" www.southtyneside.info
Page 13 of 13
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