Application for a licence to carry out acupuncture, tattooing, piercing and/or electrolysis

Transcription

1 Application for a licence to carry out acupuncture, tattooing, piercing and/or electrolysis Local Government (Miscellaneous Provisions) Act 1982 To: Peterborough City Council Licensing Team Sand Martin House Bittern Way Fletton Quays Peterborough PE2 8TY Section A: Applicant details address: Address if applying as an individual: Section B: Applicant business (skip if applying as an individual): Commercial register if registered outside of the UK: Registration Number if registered in the UK: Vat Number if registered: Legal Status: (Delete as applicable): Private Limited Company / Public Limited Company / Sole Trader Partnership / Public Body / Charity or Association Business name: Registered business address: 1

2 Section C: Agent details (Skip if you are not an agent acting on behalf of the applicant) address: Address if you are a private individual acting as an agent: Section D: Agent business (skip if you are a private individual acting as an agent) Commercial register if registered outside of the UK: Registration Number if registered in the UK: Vat Number if registered: Legal Status: (Delete as applicable): Private Limited Company / Public Limited Company / Sole Trader Partnership / Public Body / Charity or Association Business name: Registered business address: 2

3 Section E: Directors / Partners (Please give details of all directors or partners) 3

4 Section F: Practitioners Date of birth: Place of birth: Treatments to be given or supervised: Relevant qualifications: Membership of professional organisations: Date of birth: Place of birth: Treatments to be given or supervised: Relevant qualifications: Membership of professional organisations: 4

5 Date of birth: Place of birth: Treatments to be given or supervised: Relevant qualifications: Membership of professional organisations: 5

6 Section G: Details of Premises Name of premises / trading name: Mobile: Describe the premises, giving details of treatment rooms, other rooms used for the business and the facilities provided: Describe the Provision for cleaning the premises, fittings and equipment and sterilisation of instruments: Describe the provision for disposal of waste, used materials, needles, etc: If you have had an (acupuncture / tattooing / piercing / electrolysis) licence before, please give the name of the local authority: If you or any partners, directors or practitioners have ever had an application to any local authority for the grant or renewal of a skin piercing registration refused, or had a licence revoked or suspended, please give full details including date, local authority, the decision and the reason for the decision: 6

7 Section H: Opening Hours Day Of Week Opening Time Closing Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday IMPORTANT: PAYMENT MUST BE MADE BEFORE SUBMITTING THIS APPLICATION To make a payment go to: Enter Your Payment Reference Number Here: I CERTIFY THAT THE ABOVE PARTICULARS ARE CORRECT AND I AM AWARE OF LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1982 Signed: Date: Capacity: 7