Fillable Form Ref: GA05/PL/Re-instatement: APPLICATION FOR THE REINSTATEMENT OF (North Devon Council)

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Form Ref: GA05/PL/Re-instatement: APPLICATION FOR THE REINSTATEMENT OF (North Devon Council)

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The Form Ref: GA05/PL/Re-instatement: APPLICATION FOR THE REINSTATEMENT OF (North Devon Council) form is 5 pages long and contains:

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  • 12 check-boxes
  • 44 other fields

Country of origin: UK
File type: PDF

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The Licensing Team
Environmental Health & Housing
North Devon Council
Civic Centre, North Walk
Barnstaple, Devon EX31 1EA
Contact Details:
Tel: 01271 388870
Fax: 01271 388328
Email: licensing@northdevon.gov.uk
Web: www.northdevon.gov.uk/licensing
APPLICATION FOR THE REINSTATEMENT OF A PREMISES LICENCE
UNDER THE GAMBLING ACT 2005
Form Ref: GA05/PL/Re-instatement
Data Protection
North Devon Council is the Data Controller.
Your personal information will be held and used in accordance with the requirements of the
Data Protection Act 1998.
We will use the information you have provided in connection with the administration of
Licensing.
We may lawfully disclose information to other public sector agencies to:
• prevent or detect fraud and any other crime;
• support national fraud initiatives;
• protect public funds;
• progress your request for service.
We may also use basic information about you, e.g name and address, in other areas of
service provision at North Devon Council if this:
• helps you to access our services more easily;
• promotes the more efficient and cost-effective delivery of services;
• helps us to recover monies that you owe us.
We will not use your personal information in a way that may cause you unwarranted
detriment.
For further information regarding the National Fraund Initiative, please visit the Council’s
website – www.northdevon.gov/uk/fairprocessingnotice
If you require this document in an alternative format, please contact
us.
Application for the reinstatement of a premises licence under the Gambling Act 2005
PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST
If you are completing this form by hand, please write legibly in block capitals using ink. Use
additional sheets if necessary (marked with the number of the relevant question). You may wish to
keep a copy of the completed form for your records.
Section A
Individual applicant
1. Title: Mr Mrs Miss Ms Dr Other (please specify)
2. Surname: Other name(s):
[Use the names given in the applicant’s operating licence or, if the applicant does not hold an
operating licence, as given in any application for an operating licence]
3. Applicant’s address (home or business – [delete as appropriate]):
Postcode:
4(a) The number of the applicant’s operating licence (as set out in the operating licence):
4(b) If the applicant does not hold an operating licence but is in the process of applying for one,
give the date on which the application was made:
5. Tick the box if the application is being made by more than one person.
[Where there are further applicants, the information required in questions 1 to 4 should be included
on additional sheets attached to this form, and those sheets should be clearly marked “Details of
further applicants”.]
Section B
Application on behalf of an organisation
6. Name of applicant business or organisation:
[Use the names given in the applicant’s operating licence or, if the applicant does not hold an
operating licence, as given in any application for an operating licence.]
Part 1 – Applicant Details
If you are an individual, please fill in Section A. If the application is being made on behalf of an
organisation (such as a company or partnership), please fill in Section B.
7. The applicant’s registered or principal address:
Postcode:
8(a) The number of the applicant’s operating licence (as given in the operating licence):
8(b) If the applicant does not hold an operating licence but is in the process of applying for one,
give the date on which the application was made:
9. Tick the box if the application is being made by more than one organisation.
[Where there are further applicants, the information required in questions 6 to 8 should be included
on additional sheets attached to this form, and those sheets should be clearly marked “Details of
further applicants”.]
Part 2 – Premises Details
10. Trading name used at premises:
11. Give the address of the premises or, if none, give a description of the premises and its location.
Where the premises are a vessel, give the place indicated in the premises licence as the place in
the licensing authority’s area where the vessel is wholly or partly situated. Where possible this
should include an address with a postcode:
Postcode:
12. Telephone number at premises (if known):
13. Type of premises licence to be reinstated:
Regional casino Large casino Small casino
Converted Casino Bingo Adult Gaming Centre
Betting (track) Betting (other) Family Entertainment Centre
14. Premises licence number (if known):
15. If known, please give the name of the person who held the premises licence immediately
before it lapsed:
Surname: Other name(s):
16. Please indicate as accurately as you can the date on which the premises licence lapsed:
Part 3 – Details of application for reinstatement
17. Please confirm by ticking the box that you are applying for the reinstatement to take effect on
the date on which the application is granted.
18. Please set out any other matters which you consider to be relevant to your application:
Part 4 – Declarations and Checklist (Please tick as appropriate)
I/ We confirm that, to the best of my/ our knowledge, the information contained in this
application is true. I/ We understand that it is an offence under section 342 of the
Gambling Act 2005 to give information which is false or misleading in, or in relation to,
this application.
I/ We confirm that the applicant(s) have the right to occupy the premises.
Checklist:
•
Payment of the appropriate fee has been made/is enclosed
• A plan of the premises is enclosed
• The existing premises licence is enclosed
• The existing premises licence is not enclosed, but the application is
accompanied by –
• A statement explaining why it is not reasonably practicable to produce
the licence and,
• An application under the Section 190 of the Gambling Act 2005 for the
issue of a copy of the licence
• I/we understand that if the above requirements are not complied with the
application may be rejected
Part 5 – Signatures
19. Signature of applicant or applicant’s solicitor or other duly authorised agent. If signing on behalf
of the applicant, please state in what capacity:
Signature:
Print Name:
Date: (dd/mm/yyyy) Capacity:
20. For joint applications, signature of 2nd applicant, or 2nd applicant’s solicitor or other authorised
agent. If signing on behalf of the applicant, please state in what capacity:
Signature:
Print Name:
Date: (dd/mm/yyyy) Capacity:
[Where there are more than two applicants, please use an additional sheet clearly marked
“Signature(s) of further applicant(s)”. The sheet should include all the information requested in
paragraphs 19 and 20.]
[Where the application is to be submitted in an electronic form, the signature should be generated
electronically and should be a copy of the person’s written signature.]
Part 6 – Contact Details
21(a) Please give the name of a person who can be contacted about the application:
21(b) Please give one or more telephone numbers at which the person identified in question 21(a)
can be contacted:
22. Postal address for correspondence associated with this application:
Postcode:
23. If you are happy for correspondence in relation to your application to be sent via e-mail, please
give the e-mail address to which you would like correspondence to be sent:
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Form Ref: GA05PLRe-instatement: APPLICATION FOR THE REINSTATEMENT OF (North Devon Council)

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Completed 16 December 2020

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