dominos , item 319. PDF 3 MB

APPlication or a premises licence to be granted
un er the Licensing Act 2003
PLEASEREAD HE FOLLOWINGINSTRUCTIONSFIRST
f
8 fore completing this form Please ead the guidance notes at the end of the form.
If you are completing this form by h nd please write legibly in block capitals. In all cases
e sure that your answers are insid1 the boxes and written in black ink. Use additional sheets if
n cessary.
Y~ u may wish to keep a copy of th~ completed form for your records.
e Sheermans Limited
i--------------------------------------------------------------------------.(Insert name(s) of applicant)
a PIYfor a premises licence und r section 17 of the Licensing Act 2003 for the premises
d scribed in Part 1 below (the pr mises) and I/we are making this application to you as
t ~e relevant licensing authority i~ accordance with section 12 of the Licensing Act 2003
P stal address
of premises
D minos Pizza
3 7 Kenton Lane
8 Imont
or, if ,",one, ordnance
survey map reference
or description
f
Postcode
Post town I Harrow, Middlesex
Telephone number at premises (if a y)
Ndm-domestic rateable value of pre
ises
02089093666
£9100
Please state whether you are applyirg for a premises licence a
Please tick
a)
an individual or individuals *
b)
a person other than an individ
c)
d)
I
HA38RZ
o
~@@~[pLi~@
, 2 ocr 2005
[please complete section (A)
i.
as a limited company
please complete section (8)
ii.
as a partnership
please complete section (8)
iii.
as an unincorporated assbciation or
please complete section (8)
iv.
other (for example a stat
please complete section (8)
a recognised club
please complete section (8)
a charity
please complete section (8)
eB the proprietor of an education1 establishment
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a health service body
f)1
gp a person whois registereduner Part 2 ofthe
Care StandardsAct2000 (c1 ) in respect ofan
independent hospital
the chief officerof police of a police force in
h\
D
please complete section (8)
D
please completesection(8)
D
please complete section (8)
D
please complete section (8)
England and Wales
* If you are applying as a person d~scribed in (a) or (b) please confirm:
Please tick yes
.
.
I am carrying on or proPosi
to carry on a business which involves the use of
the premises for licensable ctivities; or
I am making the application ursuant to a
o statutory function or
o a function discharge~ by virtue of Her Majesty's prerogative
~
(~)INDIVIDUALAPPLICANTS
rVtr
0
Mrs
D
(filllinas applicable)
Miss
IP
example,
OtherTitleRev)
(for
First names
Ms
S~rname
0
I
D
I ~m 18 years old or over
Please tick yes
C rrent postal
a dress if different
fr m premises
a dress
i
Post Town
I
Postcode
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Daytime contact telephone numb r
Einail address
(optional)
SijCOND INDIVIDUALAPPLICANT (if applicable)
Mlr
0
Mrs
D
Miss I!J
Ms 0
Other Title (for
example, Rev)
First names
Surname
D
I am 18 years old or over
2
Please tick yes
0
o
o
qurrent postal
af:tdress if different
f.lom premises
address
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Post Town
I
Postcode
I
D~ytime contact telephone num
E~mailaddress
(qptional)
(Eh OTHER APPLICANTS
P'ease provide name and registe ed address of applicant in full. Where appropriate
p~ease give any registered numb r. In the case of a partnership or other joint venture
(qther than a body corporate), pi ase give the name and address of each party
concerned.
:
Name
S~eermans Limited
A~dress
LOndon
House
I
243-253 Lower Mortlake Road
Rfc
. hmond
l
S~rrey
TW92LL
Rtgistered number (where applicable)
2~17653
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D$scription of applicant (for exampl$, partnership, company, unincorporated association etc.)
LirlnitedCompany
T lephone number (if any)
o 089485166
E-mail address (optional)
[email protected]
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P~rt 3 Operating Schedule
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W~en do you want the premises lic$ce to start?
If Jou wish the licence to be valid only for a limited period, when do
you want it to end?
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Please give a general description the premises (please read guidance note1)
1!hepremises comprises a Domino s Pizza home delivery and takeaway store, the vast majority
of pizzas are home delivered. The tore is located in a busy shopping street.
The layout comprised a kitchen ar ,shop counter, washing up area and a small waiting area
for pizza collection bt the public. F r further details please see the attached plan.
There are no sitdown eating facility
AJlcohol
is not served, nor sold frorri, the premises.
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or more people are expect~d to attend the premises at any
one time, please state the number $xpected to attend.
Ifl5,OOO
!
What licensable activities do you intend to carry on from the premises?
(Please see sections 1 and 14 of th~ Licensing Act 2003 and Schedules 1 and 2 to the
LicensingAct 2003)
Ptovision of reaulated entertain
Please tick yes
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a)I
plays (if ticking yes, fill in box
o
b)
films (if ticking yes, fill in box
o
c).
indoor sporting events (if ticki~g yes, fill in box C)
d)
I
e~
boxing or wrestling entertainm~nt (if ticking yes, fill in box D)
o
o
o
f)
recorded music (if ticking yes,
live music (if ticking yes, fill in
g)
performances of dance (if tickihg yes, fill in box G)
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h)
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anything of a similar descriptiqn to that falling within (e), (f) or (g)
(if ticking yes, fill in box H)
o
o
o
Provision of entertainment facilit
i)
making music (if ticking yes, fi~1in box I)
j)1
dancing (if ticking yes, fill in b9x J)
entertainment of a similar desqription to that falling within (i) or U>
k)
(if ticking yes, fill
in box K)
Provision of late niaht refreshment (if ticking yes, fill in box L)
Supply
of alcohol (if ticking yes, fil~in box M)
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1nlall cases complete boxes N, 0
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o
o
o
~
o
L
Late night refreshment
Standard days and
timings (please read
guidance note 6)
Will the rovision of late night refreshment
take pi e indoors or outdoors or both please 1. ck (please read guidance note 2)
Indoors
10
-
Outdoors
ID
-
Start
Day
i
Mon
Finish
Both
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11:00 I 24:00
to_________________
Tue
I 11:00 I 24:00
Wed
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---------------..------------
Please
ive further details here (please read guidance note 3)
T akeaw y and delivery service
-------------.-------------
11:00 I 24:00
State a
seasonal variations for the rovision of late ni ht
refresh ent (pleasereadguidancenote4)
,
Thur
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1
11:00
1
24:00
------------..--------------
Fri
Sat
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------------------..-...------------
S4n
I 11:00
124:00
---------------
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ID
NI
Supply of alcohol
S~andarddays and
timings (please read
guidance note 6)
-
Day
Start
Will the
consum
guidanc
On the
premises
Offthe
premises
Both
Finish
Mon
State an seasonal variations for the su
read gui ance note4)
o
o
o
I of alcohol (please
Tue
Wed
----------------.--------------
T~ur
Fri
---------------..-------------
Sat
------------------.----------------
Sun
-----------------.-----------------
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S~te the name and details of the fndividual whom you wish to specify on the licence as
premises
supervisor
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Name
Nqt applicable
Address
~stcode
I.
Personal Licence number (if knoVl(n)
Is~uing licensing authority (if knotln)
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Pease highlight any adult entertc: inment or services, activities, other entertainment or
matters ancillary to the use of thE premises that may give rise to concern in respect of
cildren (please read guidance not 8)
Not applicable
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01
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Hc>urs premises are
oen to the public
StFlndarddays and
timings (please read
guidance note 6)
Start
Finish
Day
Mon
Tue
11:00
24:15
11:00
24:15
State an 'Jseasonal variations (please read guidance note 4)
Last ordErs as per section L, however allowing 15 minutes to
complete the cooking process
_._------------.------.-.-.------
-----------------------------------
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Wf3d
THur
Fri
Sst
11:00
-------
24:15
r--------
Non Stal dard timinas. Where vou intend the Dremises to be
ODen to he Dublic at different times from those listed in the
11:00
24:15
--------------------------------column t)nthe left Dlease list (please read guidance note 5)
11:00
01:15
---------
11:00
01:15
--------------------------------I
Sn
11:00
24:15
--------------------------------I
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b) The prevention of crime and di order
PIase see attached sheet
c) IPublic safety
Please see attached sheet
d) 'The prevention of public nuisal ce
Please see attached sheet
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e) he protection of children from harm
Please see attached sheet
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..----..--.
81
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Please tick yes
ent
of
the
fee
, have made or enclosed paY
~
, have enclosed the plan of th premises
~
I have sent copies of this appli ation and the plan to responsible authorities and
~
others where applicable
I have enclosed the consent form completed by the individualI wish to be premises
supervisor, if applicable
I understand that I must now a~vertise my application
I understand that if I do not Co~P'y withthe above requirements my application will
be rejected
~
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ITliS AN OFFENCE, LIABLE ON C NVICTION TO A FINE UP TO LEVEL 5 ON THE
STANDARD SCALE, UNDER SEC ION 158 OF THE LICENSING ACT 2003 TO MAKE A
FALSE STATEMENT IN OR IN CO~NECTION WITH THIS APPLICATION
Part 4
- Signatures
(please read guidance note 10)
Signature of applicant or applica~t's solicitor or other duly authorised agent (See
guidance note 11). If signing on b~half of the applicant please state in what capacity.
Signature
Date
Capacity
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~/
.Y-X
iv--ILv-
-
; ../ / £}/ .2(')dl~Managing Director
For joint applications
signature
o. 2ndapplicant
or 2ndapplicant's
solicitor
or other
authorised agent. (please read gui~ance note 12). If signing on behalf of the applicant
please state in what capacity.
Signature
Date
Capacity
---'I
Contact name (where not previou+ly given) and postal address for correspondence
associated with this application (Rleaseread guidance note 13)
Sarmad Shakarchi
Sheermans Limited
London House, 243-253 Lower Mortlake Road
Post town Richmond,Surrey
Post code TW92LL
Telephone number (if any)
0 089485166
If you would prefer us to corresp nd with you bye-mail your e-mail address (optional)
[email protected]
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