Brent SCHEDULE 2 regulatfon 10

NEW PREMISES LICENCE APPLICATION FORM

Application for a premises licence to be granted under the Licensing Act 2003

PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST

Before completing this fbnn please read the guidance notes at the end of the fomn. If you are completing thisfomn 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 additkmal sheets if necessary. You may wish to keep a copy of the completed form for your records.

.W.v.AT^^^ ^pply for a premises licence under section 17 of the Licensing Act 2003 for the premises described in Part 1 below (the premtees) and I/we are making this application to you as the relevant Ncensing authority in accordance with section 12 of the Licensing Act 2003

Part 1 - Premises Details

Postal address of premises or, tf rtone, ordnance survey map raferance or description

Post town LoMDo/^

Post code KvNl6-:fX<$5i

Telephone number of premies* (If any)

Non-domestic ratealile value of premiaes

Q?^8<^'2-io'^^&

£ t*&iooO' vtt

Ranises Naw Apploalion.docx

Part 2 - Applicant details

Please state whether you are applying for a premises licence as Please

a) An irwSvidual or indWduals*

b) a person other than an individual*

). as a limited company — v ^

11. as a partnership

iii. as an unincorporated association or

iv. other (for examfrfe a statutory corporation)

c) a recognised club

d) a charity

e) the proprietor of an educational establishment

i) a health service body

g) a person who is registered under Part 2 of the Care StandanJs Act 2000 (c14) in respect of an independent hospital in Wales

9a) A person who is registered under Chapter 2 of Pert 1 rrf the Health and Social Care Act 2008 (within the meaning of that Part) in an independent hospital in England

^) the chi^ oflcer of police of a police force in England and Wales

tick 1^ Yes

D

\3r D a n n a n D D

please complete section (A)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

please complete section (B)

Q please complete section (B)

[2 please complete section (B)

If you are applying as a person described in (a) or (b) please confinn:

I am carrying on or proposing to cany on a business which invohes the use of the premises for licensable activities; or

I am making the application pursuard to a o Statutory Act ion or o A function dschwged by virtue orf Her Mc^esty's prerogathe

Pleaw tick V Yes

D

D D

(A) INDIViDUAL APPUCANTS (fill in as applicable)

Mr 0 Mrs D Miss D

Surname

MsD

ft^YUg.!

I am 18 yeai« old or over

Current postal address If different from premiaes address

Post Town

Daytime contact telephone number

E^ail addraia (optional)

Other tWe D (for example, Rev)

Rrst names

MoHAMMW> H(N&l+tfA Please tick / Yes

D

Prenlses Now Appication.docx

9ECWP INPIVIpyA^. APPIIOANT (If ipp||<?«bl») V 3 j p ^

Mr C J IWrs D Miss D ivls LJ Other title (for example, Re ^ U

Surname First names

I am 18 years old or over

Current postal address if different from premises address

Post Town Postcode

Daytime contact telephone number

Please ticl( '^ Yes

D

ZZl

E-flnaii address (optional)

(B) OTHER APPLiCANTS

Please fMt)\4de name and registered address of applicant in M/Where appropriate please give any registered numtier. In case of a partnership or other joint venture (oth^Mhan a body corporate), please give the name and addr^s of each party concerned.

Name

Address

Registered number (where appHc^e)

Description of applicant (for partnership, company, unincorporated association etc.)

Telephone number Of any)

E-mail addess (optional) .

n-emises New ApplicaUon.<locx

Part 3 Operating Schedute

When do you vrant the premises licence to start?

If you wish the lic^v:e to be valid only for a limited period, when do you want It to end?

If 5,000 or more people are expected to attend the premises at any one time, please state the number expected to ati&vi

Day

0 I i\^onth

okli Year

O 1 1-

Please gi\a a geno^ description of the premises (f^ease read guidance note 1)

\jtV'^ ^^^ Stoc O f T H ^ C^HO^ Uf+ce^i

n-enises N«« Applcatkm.docx

Plsasp jipk < Y»ii

What llcensable activities do you intend to carry on from tfie premises? (Please see sections 1 and 14 of the Licensing Act 2003 and Schedule 1 aid 2 to the Licensing Act 2003)

Provtyion of regulated entertainment

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 G) 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) perfomiances of dance (If ticking yes, fill In box G) h) anything of a similar description to that Ming within (e), (f) or (g) (if ticking yes, fill In box H)

Provi^on of entertainment facilities for: i) making music (if ticking yes, fill In tox I) J) danclr^ (if ticking yes, fill in box J) k) entertainment of a similar description to that felling within (i) or (j) (if ticking y^ , fill in box K)

Provision of late niaht refreshment (if ticking yes, fill hi box L)

Sale of alcohol (if ticking yes, fill In box M)

In all cases complete boxes N, O and P

D D D a D D a D

n D D n

Plays standard days and tit (d&am rmd auittanci Day Mon

Tue

Wed

Thur

Fri

Sat

Sun

Start

nlngs nrteSi Finish

1

/ " /

Will flie performance of a play tei«) place Indoors or outdoors or boUi - please tick [V] (please t&d guidance note 2).

Indoors

Outdoors Both

pl9«ff qfvt frirttlfr ^nm »aaL(P«ease read gui^mcT note 3)

State any seasonal vaikltiom for oerformlna iHavs (crfe^e read auldance note 4)

Nori,a(l[ndard tfmlncfs. Where you Intend to use Are premises for ttie 1. . . ^ 1

DBnormanca or oiavs aianiBreni antes to inose iiswa in uie coiumn on D I B len. i -please ligt (please re%i aukkmce ncrte 5)

H^emises New Appication.cfocx

B Films standard days and timings (please read guidance note 6) Day Start Finish

Will the performance of fllms take place Indoors or outdoors or both - please ticl< [/'] (please read guidance note 2),

Indoors

Outdoors Both

Mon Pjease olvf further detells here (please read guld^ice-note 3)

Tue

Wed jg^teiny. note.4)

Thur

rlaMons for the exhibition of filmg (please r^cj wMmoe

Ibn standard tlmlnaSw Where vou Intend to use ttie Dramises for the exhibition of films at different times to ttio^ listed In the column on the left, pleaae list (please read guidance note 5

Sun

I indoor sporting events j standard days and timings 1 (ptesse read sMdance note 6) 1 Day

Mon

Tue

1 Wed

1 Tliur

Fri

Sat

Sun

1 Start Finish

u /

Please givf ftirttier ctetells (otease read guidance nrte a>

Stete anv sea«>nai variaUons forlhdoor motUmi evente (olease read cwidance j I nrte 4) -x^

Non sijindard timlnas. Where vou Intend to use ttie premises for Indoor SDCMrAna e\wnte at di^rent times te ttiose tialed In ttie column on tiw left 1 please Hst (oloase read auWance note 51 j

Fyeirises New Af^iciriion.docx

Boxing or wrestling entertainment Standard d a ^ and timings (please read guidance note B) Day Mon

Tue

Wed

Thur

Fri

Sat

Sun

Start Finish

. -

Will the boxing or wrestting entertainment take place indoors or outdoors or both - please tick [/ ] {please fsad guidance note 2).

Indoors

Outdoors

Both Please qiive ftirther details here (please read guidance nota.3)

Sttite anv seasonal variatK^ns for boxinq or wrestllncf entertainment (iiriease read quMance npte 4) /

hton starMi rd ttmlnqs. Where vou Int^ind to use the premises for boxlncj or wresUirMfentertainmentat different times to tfiose l l ^ d In the column on the ittt. Rili.!W-iiM.J[pteSg-tlSS).flriEto!^ oste 5)

1

Live Music Standard days and timings dfrtease read yjidance note 6) Day Start Finish

Will the performance of fiw music fake place indoors OT outdoors or botii - please tick [V] ((Mease read guidance note 2}

Indoors Outdoors Both

Mon Pl»a» ffive furtiwr details here

Tue

id guidance note 3)

Wed Sftite ajivaaalktnal variaBons for Bie performance of l|ve muric {xMm% read

Tliur

Fri

Sat

Sun

Man standard Bmlnqs. Where vou Intend to use tfie premises for iBte performance trf Ih/e muMc at different tfmes to Biose Hated In tte column on tfie i f ft..Pi9fft lift {p!ga8g r^d gyl Jancg nptg $)

l=Vemises New Applc8tbn.docx

1 Recorded music 1 ::)ianaara aays ana timings 1 (please read guidance note 6) 1 Day j Men

jTue

Wed

Thur

Fri

Sat

Sun

Start

/

Finish

/

/ /

Will the playing of recorded mudc take pla<» Indoors or outdoors or botii - please tick [ / ] (please read guidance note 2)

hdoors

Outdoors

Both Please give further details here (please read^uldance note 3) 1

State anv seasonaHrarlatii;Mi9 for playing recorded mu^c (crfes^e read Guidance

^ / N^n ^ n d a r d timlnafc Where vou Intend to use the premises for the o la^na of j

'^recoreled muiic at different times to those listed In the column on ttie left. 1 Dleasr l l ^ (olease read CHJkteince note 5)

Performances of dance Standard days and timings (please read guidance note 6)

Will the performance of dance laiie place indoors or outdoors or both - please tick \/\ ([Hease x&aA guidance note 2).

Please give ftirttwr deteils here (pl^ise \ ■^rfdance nc^e 3)

^arlaBons for flie performance of dance (please read

4ten s^ndard timtnas. Wt^re vou intend to use tt.e premises g i S " performance of dance at dWsrenttfmesto ttw^» HiJed in t to column on the left, pleaiw lisi ( i^ase reed tKitdare;e note 8)

Rrenrfees New A|; )lcation.docx

LJ n Anything of a similar description to tiiat failing within (e), (f) or(g} standard days and timings (please read guidance note 6)

Day Start Finish

Please give a descript ion of the act iv i t ies you w i l l be providing

Wi l l th is enter ta inment take place Indoors or outdoors or both - Please tici< T^l rpjease read guidance note i

lOons

Outdoors Both

Mon

Tue

Please give farther deta i ls here (pleasanffad guidance note 3)

Wed

Thur

$te|y any seafowlt variations for entertelnmentof a similar desolption to that falMnfl W i t h i n ^ , ffl or (g) (p|g?gg w# i gMlij^np^ npt? 41

4lon aandard timings. Where you Intend to use tiie pramlws fortbe ept»iif Ipmgnt of timfiar desgriptJon to that filling witfiln (?), (f) PT (g) f t different times to ttiose listed In Mie «>iumn on tfie lef t pleafe Hi* {p\^^^ negd gilAnc9-0g|g 5-)

Ffi

Sat

Sun

I Provision of facilities for malcing music Stamlard days and timings (please read guidance note 6)

Day Start Finish

Please give a description of ffie fadlit lesfor maldng music you wii i be providing

Will this entertainment tpike place indoors or outdSbrs Of botti - Please tick f / I (trf^se r ^ i at«d^To<rn(^e 21

Indoors Outdoors Both

Please give ftirtfier di^telis Iwtei'Dlease read outdance note 3) Mon

Tue

Wed State | iny«ftsonai variations for t te provj^on of tecHIMes tor making music (Please mSd wUmce note 4)

Thur

Fri

Sat

NOB steniterd t i m i n i ^ Where vou intend to use Bie premises for fM-o\rtrion of teeiiltlesfor maMng music at different times to tfiose Haed Intfie column on tfie left ptease i i ^ fol^e read aAfamce note 5)

Sun

Prenises New ApplicaSon.docx

Provision of fiacflitles for dancing standard days and timings (please mad guidance note 6)

Day Men

Tue

Wed

Thur

Fri

Sat

Sun J

Start

7= -r

Finish

.. „ . ™ - ^

^

Will the facilities for dancing be indoors or outdoors or b c ^ - please tick [ ] (see guidance note 2).

Indoors

Outdoors

Both

Please ^ive a desqripflon of ttie feci|ltfef for danclna you wil l be orovfdina

Please olve forflier devi ls he re -A l ^e read auidance note 3)

^

Sfiite anv seat^nal variaflons for oro^dina dandna focliltfes (please read guldance^e 4)

-^on t^ndard flmlnas. Wiiere vou intend to «m ttw oniml ie* for tlw Br«Mllon of focilitlea for dancina at different flmes to ttioce IliAed In the column on ttie left please Hit (oiease rm& auidance note 5)

1 K Provision of faciiifies for enteriahiment of a similar description to tiiat falling witiiin(i) or 0) standard days and timings (please read giAJance note 6) Day

Mon

Tira

W « l

Thur

Fri

Sat

Sun

start Finish

/

i!

Please alve a descrtpft^fi of the tyoe of entertainment foci|ity you will be p r i ^d l i j f l

Wil l Ih f f ntertplrwif ntfa<sH|ty b f I n d o p w ^ ou f t tow or b o * - Diease tick U\ (oleise raad^doTce note 2).

^ Please ah/eftHfiefdetells hem (please read auidance no

7

Indoors Outdoors

Both

te3)

X Stete anv seasonal >fflriaUons for ttie unnMon of tedlWesfor entertelnmentof a iitnllar desralotion to ttiat foiling within (11 or fl> (pl«Be ?wad ouldance note 41

ton standard tfmlnfK. Where you Intend to use flie oremises for ttie iiro\4^on of fadlllttes for entertelnment of a similar deso'lption fo th^t follii^ witfiin (1) m ni at dMforent flmes to those listed in the column on ttie left, oloase list (ote^e read audaaiep pRt? §)

1

1

10 nneirises Nsw ApplceUon.docx

Late night refreshment standard days and timings (please read guidance note 6) Da^ Mon

Tue

Wed

Thur

Fri

Sat

Sun

Stal

/ \

Finish

^

ys:.

Will file provision of late night refre^ment take place indoors or outdoors or both - please tick [V] (please read giridance note 2).

Indoors Outdoors

Both Please alve fortfier detells here tolease read auidance note 3) ^

State any f^ f ^na l variations fof%e provision of late nIaht reft^^ment (ple^^^ r^d q lctencg not? 4) ^ ^

Non^ndard tlmlnaa. Where you Intend to use thf premises forttie provision oTfate niipM refre^ment at diffisrent times, to those ii^ed In «ie column on the left. Please l i ^ (ole^e read auidance note 5)

1

M Suppfy of alcohol standard days and timings (please read piidance ncHe 6) Day I S ^ I Rnish

Will the supply of alcohol be for consumption (Please tick box i } (please read guidance note 7)

On the premises Off the prmrlses

Both Ik

Mem \kmm^.^mi0\ r^d atjfctoice note 4>

Sfeite aiw seasonal variaBons for Mie provi^on of late nloht refredwnent (please

Tue

W ^ iten-itfandard aminos. Where vou intend to use tfw premlais for flie SUPPIV of

■fhur

Fri iSM^fifiKL illiiiMcpf

Sat ^SS^^l^

Sun

!!!S>iA«l

. lic£b»iO. if^difeai

afcohtri at different times to those listed In the column on the left, please list (please read midance note 5

11 n frises New Appicatbn.docx

state the name and details of the individual whom you wish to specify on the licence as premises supervisor

Address. ■■■■Mlf

Postcode..!

Personal Licence number<lf Icnown) ^>f:*Tf^....C>0!e;,..Dw....^.|.?.*.(.V'^..

Issuing licensing authority (if loiown)

N Please highlight any adult entertainment or services; activities, other entertainment or matters ancillary to the use of the premises ttiat may ghra rise to concern in respect of children (please read giddance note 8) . ^^

^ ST^vcr Mbre \A\LA^ ie (rJ Put& THAT NO OM0,t«Z-(T^ wtu, te p.Kj.c^'^^Ho lb NO NNx«na_, CoVEe«i Fe^bce

Hours premises are open to the pubHc standard days and timings (please read guidance note 6}

Day Men

Tue

Start Rnlsh

State any seasonal variation (otease read guidance nota 4

Wed

Fri

Sat

Sun

^At<v<c? i^dj^cfic/ Won-atandard tlmltK^ Whetie vou Inland to use the oremlses to be open to the public at dlfHerent times to those Hated in the column on ttie left, nleasa list (pigflgg rwri guidance rwtg 5)

^S^M&i' HiJ^^J^^^iff

12 FYairises Nfw Appfication.docx

P Describe the steps you Inland to take to promote the four licensing objectives:

a) General - all four Hcenidng objectives (b, c, d, e) (pleaste read guidance note 9)

\/iA>e- U5itu Coi^o^ic4 ^ u FouP- UteKjiiKic, Dft-stcri^/as ,^euc,ioa«A).

b) The prevention of crime and disorder

U<t V^<\/^ Two STAP« M«-N^fi»^^ trAir«»ii> vjkA <\-T C X i t T t M - t ,

2I.^c^o CJ^IM«5 Tot^ee/MCts 9ouic2-^,

c) Public safJBty

d) The prevention of public nuisance

e) The protecflon of children Ihim harm

Ci^ (V l©Tt€ ^ A - t _ c o ^ L . VAiU. ?,e Cou€<Z-«2.D A T A \ C - T I ( L A C -

13 Ftenntees New Applcaten.docx

• \ l *■

Checklist Please tick V Yes

■ I have made or enclosed payment of the fee Si-^— I have erKilosed the plan of the premises S - — I have sent copies of this appiioeAJon and the plan to responsible authorities and others vrfiere applicable 53--^ I have enclosed the consent fonn completed by the Individual 1 vvish to be premises supenfeor, If applicable i 3 - -I underst^d that I must now advertise my application - see enclosed information leaflet B~— I understand that if I do not comply with the above requirements my application will be rejected HD-

rr 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 STATEMENTS OR IN CONNECTION WITH THIS APPLICATION

Part 4 - Signatures (please read guidance note 10)

Signature of applicant QrapplioanfsaoHutoi ui'oUier dulyauUreiiwU ayenfe (Please read guidance note 11). If ^gidng on behalf of the applicant please state in whatcapaei^.

Signature

Date ..\:^..J.Z..r..Zn^}.k.

Capacity ..X?.\.^f.fr:TS>.?-,. ltd nd

For joint applications ^gnature of 2 applicant or 2 applicants soH<dtor or other authorised agent. (Please read guidance note 12). If signing on behalf of the apgiieantpfSam s^^in what capacity.

Contact name here not previou^y given) and postal address for correspondence assoclat»d with ttiis application e ^ e read guk^nce rK>te 13)

J P i ^ town Po^ code 1 Telephone number

B-maii ackiress (clonal)

14 Rreirises New ABSfcalron.docx