Licensing Department
Application to vary a club premises certificate to be granted Under the Licensing Act 2003

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 if necessary.  You may wish to keep a copy for your records.

…………………………………………………………………………………………………………… 
(insert name of club) club applies for a club premises certificate under section 84
of the Licensing Act 2003 for the premises named in Part 1 below 

Club premises certificate number ……………………………………………………………………

Part 1 – Club premises details
Name of Club
	
Postal address of premises or, if none, ordnance survey map reference or description

Post town
	Post code	
Telephone number (if any)

	E-mail address (optional)	

Name of person performing duties of a secretary to the club
	
Postal address of person performing duties of a secretary to the club

Post town
	Post code	
Telephone number (if any)

	E-mail address (optional)	

Part 2 – Applicant details

Current postal address if different from premises address

Post town
	Post code	
Telephone number (if any)

	E-mail address (optional)	

Part 3 – Variation
									Please tick yes
Do you want the proposed variation to have effect as soon as possible?			

							          Day       Month    Year
If not do you want the variation to take effect from?				

If the club’s proposed variation would mean that 5000 or more people are expected to attend the premises at any one time, please state the number expected to attend.					

Please describe briefly the nature of the proposed variation (Please see guidance note 1)

Part 4 – Club Operating Schedule

Please complete those parts of the Club Operating Schedule which would be subject to change if this application to vary is successful

What qualifying club activities do you intend to conduct on the club premises which will be affected by your application?

Provision of regulated entertainment					Please tick  yes

a) 	plays (if ticking yes, fill in box A)						

b)	films (if ticking yes, fill in box B)						

c)	indoor sporting events (if ticking yes, fill in box C)			

d)	boxing or wrestling entertainment (if ticking yes, fill in box D)		

e)	live music (if ticking yes, fill in box E)					

f)	recorded music (if ticking yes, fill in box F)				

g)	performances of dance (if ticking yes, fill in box G)			

h)	anything of a similar description to that falling within (e), (f) or (g)		
	if ticking yes, fill in box H)

Provision of entertainment facilities for:

i)	making music (if ticking yes, fill in box i)					

j)	dancing (if ticking yes, fill in box j)					

k) 	entertainment of a similar description to that falling within (i) or (j)		
	(if ticking yes, fill in box K)

The supply of alcohol by or on behalf of a club to, or to the 
order of, a member of the club	 (if ticking yes, fill in box L)			

The sale by retail of alcohol by or on behalf of a club to a 
guest of a member of the club for consumption on the premises 
where the sale takes place (if ticking yes, fill in box L)				

In all cases complete boxes M, N, O and P

A
Plays
Standard days and timings
(please read guidance notes 6)
	Will the performance of a play take place indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give further details here (please read guidance note 3)	

Tues	

			
Weds	
		State any seasonal variations for performing plays (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for the performance of plays at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

B
Films
Standard days and timings
(please read guidance notes 6)
	Will the exhibition of films take place indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give further details here (please read guidance note 3)	

Tues	

			
Weds	
		State any seasonal variations for the exhibition of films (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for the exhibition of films at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

					

C
Indoor sporting events
Standard days and timings
(please read guidance notes 6)
	Please give further details (please read guidance note 3)
I	
Day	Start	Finish		
Mon	
		Please give further details here (please read guidance note 4)	

Tues	

			
Weds	
		State any seasonal variations for indoor sporting events (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for indoor sporting events at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

D
Boxing or wrestling entertainments
Standard days and timings
(please read guidance note 6)
	Will the boxing or wrestling entertainment take place indoors or outdoors or both – please tick 
(please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give further details here (please read guidance note 3)	

Tues	

			
Weds	
		State any seasonal variations for indoor sporting events (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for boxing or wrestling entertainment at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

E
Live music
Standard days and timings
(please read guidance note 6)
	Will the performance of live music take place indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give further details here (please read guidance note 3)	

Tues	

			
Weds	
		State any seasonal variations for the performance of live music (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for the performance of live music  at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

F
Recorded music
Standard days and timings 
(please read guidance note 6)
	Will the playing of recorded music take place indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give further details here (please read guidance note 3)	

Tues	

			
Weds	
		State any seasonal variations for theplaying of recorded music (please read guidance note 4)	

Thurs	

			
Fri	
		Non standard timings. Where you intend to use the premises for the playing of recorded music entertainment at different times to those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

G
Performances of dance 
Standard days and timings 
(please read guidance note 6)
	Will the performance of dance take place indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	

			
Tues	

			
Weds	

			
Thurs	

			
Fri	

			
Sat	

			
Sun	

			

H
Anything of a similar description to that falling within (e), (f) or(g)
Standard days and timings 
(please read guidance note 6)	Please provide a description of the type of entertainment you will be providing	
Day	Start	Finish		
Mon	
		Will this entertainment take place indoors or outdoors or both please tick (please read guidance note 2)	Indoors

Outdoors

Both		

Tues	

					
Weds	
		Please give further details here (please read guidance note 3)	

Thurs	

			
Fri	
		State any seasonal variations for entertainment of a similar description to that falling within (e), (f) or(g) (please read guidance note 4)

	
			
Sat	

		Non standard timings. Where you intend to use the premises for the entertainment of similar description to that falling within (e), (f) or (g) at different times to those listed in the column on the left, please list (please read guidance note 5)

	
Sun	

			

I
Provisions of facilities for making music
Standard days and timings 
(please read guidance note 6)
	Please give a description of the facilities for making music you will be providing	
Day	Start	Finish		
Mon	
		Will the facilities for making music be indoors, outdoors or both – please tick
(please read guidance note 2)	Indoors

Outdoors

Both		

Tues	

					
Weds	
		Please give further details here (please read guidance note 3)	

Thurs	

			
Fri		
	State any seasonal variations for the provision of facilities for making music (please read guidance note 4)	

		
Sat		

	Non standard timing. Where you intend to use the premises for provision of facilities for making music entertainment at different time to those listed in the column on the left, please list (please read guidance note 5)	
Sun		

		

J
Provision of facilities for dancing
Standard days and timings (please read guidance note 6)
	Will the facilities for dancing be indoors or outdoors or both – please tick (see guidance note 2)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		Please give a description of the facilities for dancing you will be providing	

Tues	

			
Weds	
		Please give further details here (please read guidance note 3)	

Thurs	

			
Fri	
	
	State any seasonal variations for providing facilities
(please read guidance note 4)	

Sat		

	Non standard timings. Where you intend to use the premises for the provision of facilities for dancing entertainment at different times to those listed in the column on the left, please lift (please read guidance note 5)	
Sun		

		

K
Provision of facilities for entertainment of a similar description to that falling within I or J Standard days and timings (please read guidance note 6)
	Please give a description of the type of entertainment  facility you will be providing	
Day	Start	Finish		
Mon	
		Will the entertainment facility be indoors or outdoors or both – please tick (please read guidance note 2)	Indoors

Outdoors

Both		

Tues	

					
Weds	
		Please give further details here (please read guidance note 3)	

Thurs	

			
Fri		
	State any seasonal variations for the provision of facilities for entertainment of a similar description to that falling within j or k (please read guidance note 4)	

Sat		

	Non standard timings. Where you intend to use the premises for the provision of facilities for entertainment of a similar description to that falling within I or J at different times to those listed in the column on the left, please list (please read guidance note 5)	
Sun		

		

L
Supply of alcohol
Standard days and timings (please read guidance note 6)
	Will the supply of alcohol be for consumption – please tick (please read guidance note 7)	Indoors

Outdoors

Both		
Day	Start	Finish				
Mon	
		State any seasonal variations (please read guidance note 4)	

Tues	

			
Weds	

			
Thurs	

			
Fri	
		Non standard timings.  Where the club intends to use the premises for the supply of alcohol at different times from those listed in the column on the left, please list (please read guidance note 5)	

Sat	

			
Sun	

			

M
Hours club premises are open to the members and guests
Standard days and timings (please read guidance note 6)

	State any seasonal variations (please read guidance note 4)	
Day	Start	Finish		
Mon	

			
Tues	

			
Weds	

			
Thurs	

		Non Standard timings. Where you intend to use the premises to be open to the members and guests at different times from those listed in the column on the left, please list. (please read guidance note 5)	
Fri	

	
			
Sat	

			
Sun	

			

N
Please highlight any adult entertainment or services, activities, other entertainment or matters ancillary to the use of the premises that may give rise to concern in respect of children (Please read guidance note 8)

	

O
Please identify those conditions currently imposed on the certificate which you believe could be removed as a consequence of the proposed variation you are seeking.

	

									Please tick yes
I have enclosed the club premises certificate						

I have enclosed the relevant part of the club premises certificate				

If you have not ticked one of these boxes please fill in the reasons for not including the certificate, or part of it below

Reasons why the club has failed to enclose the club premises certificate or relevant part of it

	

P Describe the steps you intend to take to promote the four licensing objectives

a) General – all four licensing objectives (b,c,d,e) (please read guidance note 9)

	

b) The prevention of crime and disorder

	

c) Public safety

	

d) The prevention of public nuisance

	

e) The protection of children from harm

	

								             Please tick  yes

•	I have made or enclosed payment of the fee				
•	I have sent copies of this application and the plan to the responsible		
authorities and others where applicable					
I have completed and enclosed the club declaration and enclose 		
a copy of the club rules							
•	I understand that I must now advertise my application			
•	In understand that if I do not comply with the above requirements my	
application will be rejected

IT IS AN OFFENCE, LIABLE ON CONVICTION TO A FINE UP TO LEVEL 5 ON THE STANDARD SCALE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKE A FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION

Part 5 – Signatures (please read guidance note 10)

I (Insert full name) …………………………………………………………… make this application on behalf of the club and have authority to bind the club

Signature…………………………………………………………………………………………..

Date…………………………………………………………………………………………………

Capacity……………………………………………………………………………………………

Address for correspondence associated with this application (please read guidance note 11)

	
Post town
	Post code	
Telephone number (if any)
	
 If you would prefer us to  correspond with you by email your email address (optional)

Personal Data
We have recently updated our Privacy Notice about how we use personal data provided to the Council. Further information can be found at:
http://www.kirklees.gov.uk/beta/information-and-data/pdf/privacy-notice-licensing-gambling-act.pdf

Notes for Guidance

1.	Describe the premises. For example the type of premises, its general situation and layout and any other information which could be relevant to the licensing objectives. Where your application includes off-supplies of alcohol and you intend to provide a place for consumption of these off-supplies you must include a description of where the place will be and its proximity to the premises.

2.	Where taking place in a building or other structure please tick as appropriate. Indoors may include a tent.

3.	For example the type of activity to be authorised, if not already stated, and give relevant further details, for example (but not exclusively) whether or not music will be amplified or unamplified.

4.	For example (but not exclusively), where the activity will occur on additional days during the summer months.

5.	For example (but not exclusively), where you wish the activity to go on longer on a day e.g. Christmas Eve

6.	Please give timings in 24 hour clock (e.g. 16:00) and only give details for the days of the week you when you intend the premises to be used for the activity.

7.	If the club wishes members and their guests to be able to consume alcohol on the premises please tick on, if you wish people to be able to purchase alcohol to consume away from the premises please tick off. If you wish people to be able to do both please tick both.

8.	Please give information about anything intended to occur at the premises or ancillary to the use of the premises which may give rise to concern in respect of children, regardless of whether you intend children to have access to the premises, for example (but not exclusively) nudity or semi nudity, films for restricted age groups, the presence of gaming machines.

9.	Please list here steps you will take to promote all four licensing objectives together.

10.	The application form must be signed by someone with authority to bind the club

11.	This is the address we shall use to correspond with you about this application.