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 TO VARY A PREMISES LICENCE
UNDER THE GAMBLING ACT 2005
Form Ref: GA05/PL/Variation
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 to vary 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 licensed 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 varied:
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 you are making this application alongside an application for transfer or reinstatement of the
premises licence into your name, please give the name of the current licence holder as it appears
on the premises licence (if known):
Surname: Other name(s):
Part 3 – Details of variations applied for
16(a) Please give details of any variation which is being applied for. Where the application
includes an application to exclude or vary a condition of the premises licence, identify the relevant
condition here (unless it relates to hours of operation which are dealt with in questions 16(b) and
16(c)):
16(b) Do you want the licensing authority to exclude or vary a condition of the licence so that the
premises may be used for longer periods than would otherwise be the case?
Yes/No [delete as appropriate]
16(c) If the answer to question 16(b) is yes, please complete the table below to indicate the times
when you want the premises to be available for use under the premises licence.
Start Finish Details of any seasonal variation
Mon
hh:mm hh:mm
Tue
Wed
Thurs
Fri
Sat
Sun
17. Please indicate any particular date on which you want the variation to take effect if approved:
(dd/mm/yyyy)
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
I/ we understand that it is now necessary to advertise the application and give
the appropriate notice to the responsible authorities
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.]
click to sign
signature
click to edit
click to sign
signature
click to edit
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: