Fillable Standard applicant profile section 1 (Breckland District Council)

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Standard applicant profile section 1 (Breckland District Council)

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  • 9 check-boxes
  • 118 other fields

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File type: PDF

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Standard applicant profile section 1
1 Reference number
1.1 System reference Number (if known)
1.2 Your reference (if known)
Please complete all the questions in the form.
If you have nothing to record, please state "Not applicable" or "None"
2a Agent
2.1
Are you an agent acting on behalf of the
applicant
Yes No
If no, go to 3.1
2b Further information about the Agent
2.2 Name
2.3 Address
2.4 Email
2.5 Main telephone number
2.6 Other telephone number
3 Applicant details
3.1 Name
3.2 Address
3.3 Email
3.4 Date of birth:
3.5 Main telephone number
3.6 Other telephone number
3 Applicant details
3.7
Are you applying as a business or
organisation, including a sole trader
Yes No
3.8 Are you applying as an individual Yes No
4a Applicant Business
4.1
Is your company registered with
companies house
Yes No
If no, go to 4.3
4.2 Registration Number
4.3
Is your business registered outside the
UK
4.4 VAT Number
4.5 Legal status of the business, explain?
4.6 Your position in the business
4.7
The country where your head office is
located.
4b
Business Address – This should be your official address – The address required of you by law to
receive all communication
4.8 Building name or number
4.9 Street
4.10 District
4.11 City or Town
4.12 County or administrative area
4.13 Postcode
4.14 Country
The Animal Welfare (Licensing of Activities Involving Animals) (England)
Regulations 2018
Application for a licence to provide or arrange for the
provision of boarding for cats or dogs
Please complete all the questions in the form.
If you have nothing to record, please state "Not applicable" or "None"
1a Type of Application
1.1
Commercial
Boarding
Home
Boarding
Day Care
1.2 Type of Application New Renewal
1.3 Existing licence number (if applicable)
1b Animals to be accommodated
1.4 Cats
Yes No
Maximum number
1.5 Dogs
Yes No
Maximum number
2 Premises to be licensed
2.1 Name of premises/trading name
2.2
Address of premises
2.3 Telephone number of premises
2.4 Email address
2.5
Do you have planning permission for
this business use? When was this
granted?
Yes No Granted
3 Accommodation and facilities
3.1
Details of the quarters used to
accommodate animals, including
number, size and type of construction
3.2. Exercise facilities and arrangements
3.3 Heating arrangements:
3.4 Method of ventilation of premises
3.5
Lighting arrangements (natural &
artificial)
3 Accommodation and facilities
3.6 Water supply
3.7 Facilities for food storage & preparation
3.8
Arrangements for disposal of excreta,
bedding and other waste material
3.9
Isolation facilities for the control of
infectious diseases
3.10
Fire precautions/equipment and
arrangements in the case of fire and
other emergencies
3.11
How do you keep and maintain a
register of animals?
Paper Electronic
3.12
How do you propose to minimise
disturbance from noise?
3.13 Security details, i.e. fencing, gates etc
4 Veterinary surgeon
4.1 Name of usual veterinary surgeon
4.2 Company name
4.3 Address
4.4 Telephone number
4.5 Email address
5a Emergency key holder
5.1 Do you have an emergency key holder?
Yes No
If no, go to 6.1
5.2 Name
5.3 Position/job title
5.4 Address
5.5 Daytime telephone number
5.6 Evening/other telephone number
5.7 Email address
5.8 Add another person?
Yes No
If no, go to 6.1
5b Emergency key holder 2
5.9 Name
5.10 Position/job title
5.11 Address
5.12 Daytime telephone number
5.13 Evening/other telephone number
5.14 Email address
6 Public liability insurance
6.1 Do you have public liability insurance?
Yes No
If no, go to 6.7
6.2
Please provide details of the policy
6.3 Insurance company
6.4 Policy number
6.5 Period of cover
6.6 Amount of cover (£)
6.7
Please state what steps you are taking
to obtain such insurance
7 Disqualifications and convictions
Has the applicant, or any person who will have control or management of the establishment, ever been
disqualified from:
7.1 Keeping a pet shop?
Yes No
7.2 Keeping a dog?
Yes No
7.3 Keeping an animal boarding establishment?
Yes No
7.4 Keeping a riding establishment?
Yes No
7.5 Having custody of animals?
Yes No
7.6
Has the applicant, or any person who will have control or
management of the establishment, been convicted of any
offences under the Animal Welfare Act 2006?
Yes No
7 Disqualifications and convictions
7.7
Has the applicant, or any person who will have control or
management of the establishment, ever had a licence
refused, revoked or cancelled?
Yes No
7.8
If yes to any of these questions,
please provide details,
8 Additional details
Please check local guidance notes and conditions for any additional information which may be required
8.1
Additional information which is
required or may be relevant to
the application
Standard declaration section
1 Model Licence Conditions & Guidance
All applicants to tick that they have read the applicable model licence conditions and guidance
1.1 Selling animals as pets
1.2
Providing or arranging boarding for cats
or dogs
1.3 Exhibition of animals
1.4 Hiring out horses
1.5 Breeding dogs
2 Additional Information
Please attach the following Information and tick once completed:
2.1 A plan of the premises
2.2 Insurance policy
2.3
Written operating procedures to include
emergency plan, staff training policy
2.4 Risk Assessments (including Fire)
2.5
Management of the following – feeding,
cleaning, transportation, disease control,
health and welfare, death or escape
2.6 Qualifications
2.7 Training/experience records
3 Declaration
3.1
This section must be completed by the applicant. If you are an agent please ensure this section is completed
by the applicant.
3.2
I am aware of the provisions of the relevant Act and model licence conditions. The details contained in the
application form and any attached documentation are correct to the best of my knowledge and belief. It is an
offence to give false information.
3.3
Signing this box indicates you have read
and understood the above declaration
Signature:
3.4 Full Name
3.5 Capacity
3.6 Date
Notes – Persons who may not apply for a licence
1. A person who has at any time held a licence which was revoked under regulation 15 of these
Regulations.
2. A person who has at any time held a licence which was revoked under regulation 17 of the Animal
Welfare (Breeding of Dogs) (Wales) Regulations 2014(a).
3. A person who has at any time held a licence which was revoked under regulation 13 of the Welfare of
Wild Animals in Travelling Circuses (England) Regulations 2012(b).
4. A person who is disqualified under section 33 of the Welfare of Animals Act (Northern Ireland) 2011(c).
5. A person who has at any time held a licence which was revoked under regulation 12 of the Welfare of
Racing Greyhounds Regulations 2010(d).
6. A person who is disqualified under section 34 of the Act.
7. A person who is disqualified under section 40(1) and (2) of the Animal Health and Welfare (Scotland)
Act 2006(e).
8. A person who is disqualified under section 4(1) of the Dangerous Dogs Act 1991(a).
9. A person who is disqualified under Article 33A of the Dogs (Northern Ireland) Order 1983(b).
10. A person who is disqualified under section 6(2) of the Dangerous Wild Animals Act 1976(c) from
keeping a dangerous wild animal.
11. A person who is disqualified under section 3(3) of the Breeding of Dogs Act 1973(d) from keeping a
breeding establishment for dogs.
12. A person who is disqualified under section 4(3) of the Riding Establishments Act 1964(e) from keeping a
riding establishment.
13. A person who is disqualified under section 3(3) of the Animal Boarding Establishments Act 1963(f) from
keeping a boarding establishment for animals.
14. A person who is disqualified under section 5(3) of the Pet Animals Act 1951(g) from keeping a pet shop.
15. A person who is disqualified under section 1(1) of the Protection of Animals (Amendment) Act 1954(h)
from having custody of an animal.
16. A person who is disqualified under section 4(2) of the Performing Animals (Regulation) Act 1925(i).
17. A person who is disqualified under section 3 of the Protection of Animals Act 1911(j) from the ownership
of an animal.
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How to pay
Breckland Council, Elizabeth House, Walpole Loke, Dereham, Norfolk, NR19 1EE
By paying by debit card or credit card we can process your application more quickly.
To pay by card please complete and return this form to:
Licensing Payment, Breckland Council, Elizabeth House, Walpole Loke, Dereham, Norfolk, NR19 1EE
This form will be destroyed once the card has been debited.
Debit/Credit card details
Licence number (if known): ...........................................................................................................
Applicant’s name: ...........................................................................................................
Applicant’s address: ...........................................................................................................
...........................................................................................................
Postcode: ..................................................................................
Cardholder’s name: ...........................................................................................................
Cardholder’s telephone number: ...........................................................................................................
Cardholder’s email address: ...........................................................................................................
Cardholder’s address: ...........................................................................................................
...........................................................................................................
Postcode: ..................................................................................
Amount to debit: £………………………………
Card number:
Valid from /
Expires end /
Security number
Card issue number* What is the Security Number?
*Maestro/Cirrus only
Cardholder’s signature: ................................................... Date: ............................................
Other methods of payment
Cheques made payable to Breckland Council
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Standard applicant profile section 1 (Breckland District Council)

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Completed 9 February 2021

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