Fillable establishment Application for a licence to operate an (Harlow District Council)

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establishment Application for a licence to operate an (Harlow District Council)

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Page 1 of 5
The Animal Welfare (Licensing of Activities Involving Animals) Regulations 2018
Application for a licence to operate an animal boarding
establishment
Please complete all the questions in the form.
If you have nothing to record, please put "n/a" or "none"
Applicant Profile Section
1
Reference number
1.1
System reference number
1.2
Your reference
1.2a
Agent
1.2.1
Are you an agent acting on behalf of
the applicant?
Yes
No
1.2b
Further information about the agent
1.2.2
Name
1.2.3
Address
1.2.4
Email
1.2.5
Main telephone number
1.2.6
Other telephone number
1.3
Applicant details
1.3.1
Name
1.3.2
Address
1.3.3
Email
1.3.4
Main telephone number
1.3.5
Other telephone number
1.3.6
Applying as a business or
organisation, including a sole trader
Yes No
1.3.7
Applying as an individual
Yes No
1.4a
Applicant business
1.4.1
Is your company registered with
companies house?
Yes No If no go to 1.4.3
1.4.2
Registration number
1.4.3
Is your business registered outside the
UK?
1.4.4 VAT number
1.4.5 Legal status of the business
Page 2 of 5
1.4a
Applicant business
1.4.6 Your position in the business
1.4.7
The country where your head office is
located
1.4.7b
Business address – this should be your official address – the address required of you by law to
receive all communication
1.4.8
Building name or number
1.4.9
Street
1.4.10
District
1.4.11
City or town
1.4.12
County or administrative area
1.4.13
Post code
1.4.14
Country
Type of Business Section
2
Type of application
2.1
Commercial boarding
Home
boarding
Day care
2.2
Type of application
New
Renewal
2.3
Existing licence
number
2a
Animals to be accommodated
2.4 Cats Yes No Maximum number
2.5 Dogs Yes No Maximum number
2b
Further information about the applicant
2.6
Date of birth
3
Premises to be licensed
3.1 Name of premises/trading name
3.2 Address of premises
3.3 Telephone number of premises
3.4 Email address
3.5
Do you have planning permission for
this business use?
Yes No
4
Accommodation and facilities
4.1
Details of the quarters used to
accommodate animals, including number,
size and type of construction
4.2
Exercise facilities and arrangements
4.3 Heating arrangements
Page 3 of 5
4
Accommodation and facilities
4.4 Method of ventilation of premises
4.5
Lighting arrangements (natural and
artificial)
4.6 Water supply
4.7 Facilities for food storage and preparation
4.8
Arrangements for disposal of excreta,
bedding and other waste material
4.9
Isolation facilities for the control of
infectious diseases
4.10
Fire precautions/equipment and
arrangements in the case of fire
4.11
Do you keep and maintain a register of
animals?
Yes No
4.12
How do you propose to minimise
disturbance from noise?
5
Veterinary surgeon
5.1 Name of usual veterinary surgeon
5.2 Company name
5.3 Address
5.4 Telephone number
5.5 Email address
6a
Emergency key holder 1
6.1 Do you have an emergency key holder? Yes No If no, go to 7.1
6.2
Name
6.3
Position/job title
6.4
Address
6.5 Daytime telephone number
6.6 Evening/other telephone number
6.7 Email address
6.8 Add another person? Yes No If no, go to 7.1
6b Emergency key holder 2
6.9
Name
6.10
Position/job title
6.11
Address
6.12 Daytime telephone number
6.13 Evening/other telephone number
6.14 Email address
Page 4 of 5
7
Public liability insurance
7.1 Do you have public liability insurance? Yes No If no, go to question 7.6
If yes, please provide details of the policy
7.2 Insurance company
7.3 Policy number
7.4 Period of cover
7.5 Amount of cover (£m)
7.6
Please state what steps you are taking to
obtain such insurance
8
Disqualifications and convictions
Has the applicant, or any person who will have control or management of the establishment, ever been
disqualified from:
8.1
Keeping a pet shop?
Yes
No
8.2
Keeping a dog?
Yes
No
8.3
Keeping an animal boarding establishment?
Yes
No
8.4
Keeping a riding establishment?
Yes
No
8.5
Having custody of animals?
Yes
No
8.6
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
8.7
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
8.8
If yes to any of these questions, please provide details
9
Additional details
Please check local guidance notes and conditions for any additional information which may be required
9.1
Additional information which is required or may be
relevant to the application
Payment and Declaration Section
10 Payment
10.1
Payment must be made at the time of making the application
10.2
Please see website page for the relevant fees
11
Model licence conditions and guidance
All applicants to tick that they have read the applicable model licence conditions and guidance
11.1
Selling pets
11.2
Animal boarding
11.3
Performing animals
11.4
Riding establishments
11.5
Dog breeding
Page 5 of 5
12
Additional information
Please attach the following information
12.1
A plan of the premises
12.2
Insurance policy
12.3
Operating procedures
12.4
Risk assessments (including fire)
12.5
Infection control procedure
12.6
Qualifications
12.7
Training records
13
Declaration
13.1
This section must be completed by the applicant. If you are an agent please ensure this section is completed
by the applicant
13.2
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.
13.3
Ticking this box indicates you have read
and understood the above declaration
13.4
Full name
13.5
Capacity
13.6
Date
Please return this application form to:
Environmental Health Services
Harlow Council
Civic Centre
The Water Gardens
Harlow
Essex CM20 1WG
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establishment Application for a licence to operate an (Harlow District Council)

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Completed 1 August 2020

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