Nottinghamshire County Council Act 1985 (PartIV)
APPLICATION FOR
NEW LICENCE, TRANSFER OR RENEWAL OF LICENCE
FOR THE OPERATION OF AN ESTABLISHMENT
FOR MASSAGE OR SPECIAL TREATMENT
SECTION 1
To be fully completed by the applicant in all cases
I/We hereby apply for a licence: (delete as appropriate) Grant / Transfer/Renewal
PLEASE COMPLETE IN BLACK INK AND IN BLOCK CAPITALS.
All sections must be completed if applicable. (If not applicable please state N/A)
1 / Name of Applicant2 / Maiden /Former Name(s)
3 / Date Of Birth /Place of birth
4 / Applicant’s home address
Post Code
Telephone Number
e-mail address
5 / In the case of a company, society, association or other body, give the registered office (and principal office if different) and names and private addresses of the directors or other persons responsible directly or indirectly for the management of the establishment.
Post Code
Telephone Number
6 / Trading name of premises to be licensed
7 / Address of premises to be licensed
Post Code
Telephone Number
e-mail address
8 / Is the applicant the sole owner of the premises / YES
NO / Please ensure that section 3 of the application form is fully completed by the owner of the premises
9 / Is the applicant the sole owner of the business / YES
NO / Please ensure that section 4 of the application form is fully completed by the owner of the business
10 / Is the applicant the manager of the business / YES
NO / Please ensure that section 5 of the application is fully completed by the manager of the business
11 / Give details of any interest including employment in any other establishment for massage or special treatment within the UK. (Please tick the appropriate box) / N/A
YES
WHERE?
12 / Has the applicant been convicted under the Sexual Offences Act 1956 to 1985 or the Street Offences 1959
(Please tick the appropriate box.) / NO
YES
13 / Has the applicant been convicted of any other criminal offence
N.B. Criminal convictions are not an automatic bar to the granting of a licence / No
YES
14 / Will the applicant normally be in attendance at the establishment?
(tick as appropriate) / YES / Full time
Part time
NO / If no, the person who is the actual and responsible manager of the establishment must complete section 5 of the form attached.
15 / Please state what activities are provided at the premises.
A) Massage
B) Electric treatment or radiant heat, light or electric vapour treatment
C) Sauna or other baths for therapeutic treatment
D) IPL/Laser treatments
E) Other similar treatments (please specify)…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… / Please delete as appropriate all that apply
Aromatherapy YES/NO
Acupressure massage YES/NO
Body wrap (where massage is applied) YES/NO
Collagen Lamps YES/NO
Full body massage YES/NO
Galvanic treatment/none surgical face lift YES/NO
Hand applied tan YES/NO
Hot Stones YES/NO
IPL/Laser YES/NO
LA Stone Therapy YES/NO
Part body massage YES/NO
Shiatsu (without clothing) YES/NO
Communal Sauna; Steam room;
Turkish/Hydrotherapy Bath;Sauna YES/NO
Sun beds YES/NO
Thai Yoga Bodywork (if includes massage) YES/NO
Other similar treatments YES/NO
(activities at the premises even though no licence is required)
16 / Give details of technical qualifications, training courses, diplomas, experience etc of the applicant for carrying on of that business. Evidence of qualifications must be submitted
Photocopies will not be accepted.
Use a separate sheet if necessary.
17 / Describe the premises
1. No of rooms
2. Give details of arrangements for cleansing of premises, fittings and equipment A separate sheet may be used if necessary
18 / Will the massage or special treatment be available for:
Tick as appropriate / Men only
Women only
Both sexes
if both sexes, state whether:
Mixed sessions
Single sessions
19 / The applicant must provide the name and addresses of 2 referees (who must not be relatives) al least one of which should be a professional referee.
N.B. These may be contacted / 1.
2.
DECLARATION: I declare that the information that I have provided is correct to the best of my knowledge and understand that I will be guilty of an offence if I knowingly provide false information.
Signature / Date
/ BROXTOWE BOROUGH COUNCIL
Nottinghamshire County Council Act 1985 (PartIV)
APPLICATION FOR NEW LICENCE, TRANSFER OR RENEWAL OF LICENCE FOR THE OPERATION OF AN ESTABLISHMENT FOR MASSAGE OR SPECIAL TREATMENT
SECTION 2
To be completed by all persons who are or will be engaged in giving hands on treatment. Treatment includes massage, aromatherapy, etc
Each person must sign to confirm his or her details.
New practitioners must supply a recent passport-sized photograph for identification purposes, signed and dated on the reverse together with their Qualification Certificates.
PLEASE COMPLETE IN BLACK INK AND IN BLOCK CAPITALS
1 / Applicants full name2 / Maiden /Former Name(s)
3 / Date Of Birth /Place of birth
4 / Full home address
Post Code
Telephone Number
5 / e-mail address
6 / Give details of technical qualifications, training courses, diplomas, experience etc. of the applicant for the carrying on of that business. Evidence of qualifications must be submitted.
Original certificates must be provided,
(photocopies will not be accepted.)
Use a separate sheet if necessary
7 / Has the applicant been convicted under the Sexual Offences Acts 1956 to 1985 or the street Offences Act 1959. / NO…………YES…………
If YES give details.
………………………………………………………………………………………………………………
8 / Has the applicant been convicted of any other criminal offences?
N.B. Criminal convictions are not an automatic bar to the granting of a licence / NO…………YES…………
If YES give details.
………………………………………………………………………………………………………………………………………………………………………
9 / Name of premises to be employed at. / ………………………………………………………………………………………………………………………………………………………………………
10 / Please state what treatments you will provide at the establishment
A) Massage
B) Electric treatment or radiant heat, light or electric vapour treatment
C) Sauna or other baths for therapeutic treatment
D) IPL/Laser treatments
E) Other similar treatments (please specify)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… / Please indicate as appropriate all that apply
Aromatherapy YES/NO
Acupressure massage YES/NO
Body wrap (where massage is applied) YES/NO
Collagen Lamps YES/NO
Full body massage YES/NO
Galvanic treatment/non surgical face lift YES/NO
Hand applied tan YES/NO
Hot Stones YES/NO
IPL/Laser YES/NO
LA Stone Therapy YES/NO
Part body massage YES/NO
Shiatsu (without clothing) YES/NO
Communal Sauna: Steam Room;
Turish/Hydrotherapy Bath; Sauna YES/NO
Sun beds YES/NO
Thai Yoga Bodywork (if includes massage) YES/NO
Other similar treatments YES/NO
DECLARATION: I declare that the information that I have provided is correct to the best of my knowledge and understand that I will be guilty of an offence if I knowingly provide false information.
Signature / Date
This form may be photocopied as many times as necessary such that all practitioners can provide their details.
/ BROXTOWE BOROUGH COUNCIL
Nottinghamshire County Council Act 1985 (PartIV)
APPLICATION FOR NEW LICENCE, TRANSFER OR RENEWAL OF LICENCE FOR THE OPERATION OF AN ESTABLISHMENT FOR MASSAGE OR SPECIAL TREATMENT
SECTION 3
To be completed by the OWNER of the PREMISES (i.e. LANDLORD), where the owner is NOT also the applicant
PLEASE COMPLETE IN BLACK INK AND IN BLOCK CAPITALS
1 / Name of Owner of premises2 / Maiden /Former Name(s)
3 / Date Of Birth /Place of birth
4 / Owner’s home address
Post Code
Telephone Number
e-mail address
5 / Has the premises owner any business interest (apart from the landlord)?
(Please tick the appropriate box) / YES
NO
6 / Is the premises owner aware of the intended business?
(Please tick the appropriate box) / YES
NO
6 / Has the premises owner been convicted under the Sexual Offences Acts 1956 to 1985 or the street Offences Act 1959?
(Please tick the appropriate box) / YES
NO
7 / Has the premises owner been convicted of any other criminal offences?
N.B. Criminal convictions are not an automatic bar to the granting of a licence / YES
NO
DECLARATION: I declare that the information that I have provided is correct to the best of my knowledge and understand that I will be guilty of an offence if I knowingly provide false information.
Signature / Date
This form may be photocopied as many times as necessary such that all practitioners can provide their details.
/ BROXTOWE BOROUGH COUNCIL
Nottinghamshire County Council Act 1985 (PartIV)
APPLICATION FOR NEW LICENCE, TRANSFER OR RENEWAL OF LICENCE FOR THE OPERATION OF AN ESTABLISHMENT FOR MASSAGE OR SPECIAL TREATMENT
SECTION 4
To be completed by the OWNER of the BUSINESS, where the owner is NOT also the applicant or the owner of the premises
PLEASE COMPLETE IN BLACK INK AND IN BLOCK CAPITALS
1 / Name of Owner of business2 / Maiden /Former Name(s)
3 / Date Of Birth /Place of birth
4 / Business Owner’s home address
Post Code
Telephone Number
5 / Has the owner of the business been convicted under the Sexual Offences Acts 1956 to 1985 or the street Offences Act 1959.
(Please tick the appropriate box) / YES
NO
6 / Has the owner of the business been convicted of any other criminal offences?
(Please tick the appropriate box)
N.B. Criminal convictions are not an automatic bar to the granting of a licence / YES
NO
7 / Has the owner of the business any interest including employment in any other establishment for massage and special treatment within the U.K.
(Please tick the appropriate box) / YES
NO
Where ………………………………………………………………………………………………………………………………………………………………………………………………………………………………
DECLARATION: I declare that the information that I have provided is correct to the best of my knowledge and understand that I will be guilty of an offence if I knowingly provide false information.
Signature / Date
This form may be photocopied as many times as necessary such that all practitioners can provide their details.
/ BROXTOWE BOROUGH COUNCIL
Nottinghamshire County Council Act 1985 (PartIV)
APPLICATION FOR NEW LICENCE, TRANSFER OR RENEWAL OF LICENCE FOR THE OPERATION OF AN ESTABLISHMENT FOR MASSAGE OR SPECIAL TREATMENT
SECTION 5
To be completed by the MANAGER of the BUSINESS, where the manager is NOT also the applicant or the owner of the premises or the owner of the business
PLEASE COMPLETE IN BLACK INK AND IN BLOCK CAPITALS
1 / Name of manager of business2 / Maiden /Former Name(s)
3 / Date Of Birth /Place of birth
4 / Manager’s home address
Post Code
Telephone Number
5 / Give details of technical qualifications, training courses, diplomas, experience etc. of the manager for the carrying on of that business. Evidence of qualifications must be submitted in respect of new managers if applicable.
Original certificates must be provided.
6 / Has the manager of the business been convicted under the Sexual Offences Acts 1956 to 1985 or the street Offences Act 1959. / YES
NO
7 / Has the manager of the business been convicted of any other criminal offences?
(Please tick the appropriate box) / YES
NO
N.B. Criminal convictions are not an automatic bar to the granting of a licence
8 / Has the manager of the business any interest including employment in any other establishment for massage and special treatment within the U.K.
(Please tick the appropriate box) / YES
NO
WHERE……………………………………………………………………………………………………………………………………………………………
DECLARATION: I declare that the information that I have provided is correct to the best of my knowledge and understand that I will be guilty of an offence if I knowingly provide false information.
Signature / Date
This form may be photocopied as many times as necessary such that all practitioners can provide their details.