Fillable Skin Piercing Premises Application E-form December 2019 - Skin_Piercing_Premises_Application_E-form_May 2018-19

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Skin Piercing Premises Application E-form December 2019 - Skin_Piercing_Premises_Application_E-form_May 2018-19

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Local Government (Miscellaneous Provisions) Act 1982
Local Government Act 2003
Acupuncture, Tattooing, Semi Permanent Skin Colouring, Cosmetic Piercing and Electrolysis
Premises Registration Application
To Guildford Borough Council, I/We hereby apply for a Premises Registration to carry on the:
(Tick ALL that apply)
Practice of Acupuncture

Business of Tattooing

Business of Semi-Permanent Skin-Colouring

Business of Cosmetic Piercing

Business of Electrolysis

1. Applicant
Title
Forename
Surname
Address of Applicant
ie usual place of
residence, or in the
case of a company or
firm, the registered or
principle office
Telephone Number
Mobile Number
Email Address
2. Premises to be Registered
Name (if any)
Address (with postcode)
Telephone number
Description of
premises, including
number of rooms
and particulars of
arrangements for
cleansing of
premises, fittings
and equipment and
sterilisation of
instruments (attach
separate schedule if
necessary):
Is this a new business
Yes / No
3. Particulars
1. Have you previously been
registered in this respect in
any other district?
Yes / No
If Yes, give district and
registration details:
2.
Have you ever been convicted
of any offence under these or
any related Acts?
Yes / No
If Yes, please provide details:
3. Particulars of relevant
qualifications and details of
certificate(s):
Note - Original certificates may be required for inspection when routine Health and Safety Inspections are
carried out.
4. Are you a member of a
professional body or
association?
Yes / No
If Yes, please provide details:
4. Declaration
I understand my/ our responsibilities under the Act
I declare that the information that I/ we have given is complete and correct.
I have paid the appropriate fee by calling 01483 505050
I enclose valid public liability insurance
I enclose copies of training certificates
I enclose copies of Sharps Waste Collection Agreement
I enclose copies of Client Medical Questionnaires
Signature: Date:
The information you provide on this form will be used by Guildford Borough Council for
licensing purposes. We may share your information and make any other necessary enquiries
regarding your application with other departments and statutory organisations in relation to the
application. Your personal information will be processed in line with Data Protection legislation
and we will not disclose information about you to anyone outside the Council unless the law
permits or requires us to.
We will retain your data for as long as it is required for our administrative use, after which it will
be securely disposed of.
If you believe the data we process on you is incorrect you may request to see this information
and, if necessary have it corrected or deleted. If you wish to raise a complaint you can contact
our Data Protection Officer at the address below. If you believe we are not processing your
data lawfully you can complain to the Information Commissioner’s Office (https://ico.org.uk/).
Further details are available on our website - https://www.guildford.gov.uk/dataprotection, or
from the Information Rights Officer, Guildford Borough Council, Millmead House, Millmead,
Guildford, GU2 4BB (email: foi@guildford.gov.uk).
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Skin Piercing Premises Application E-form December 2019 - Skin_Piercing_Premises_Application_E-form_May 2018-19

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Completed 7 July 2020

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