#b?riff:fr"n' 1st April 2017 * 313t March 2018 S.T.A.R / I

London Local Authorities Act 1991 - Special Treatment Licence

This Application form is gnly for a Renewal of an existing licence that had been issued for and'betwe6n the period of lflApril 2016 - 31sr March 2017 '

This form must not be used and signed if the following have happened-'1. New treatments are being aOOed that were not on the previous licence-.Z. New therapist/s have been, or will be, engaged at the time this application statement E

s igned. : r " ' ' " ' " , , ; ' . : '3. Tile named person of the licence has left the business and has no further position of

control in thl management of any licensable activity or conduct of the premises.

lf at any time after the licence has been issued you subsequently meet po.ints 1, 2 &3 above you

MUST inform the Health & Safety Licensing Teim of these changes. Failure to do so will mean

tttat Vou are not complying with the terms & conditions that the licence has being granted for.

In addition to signing the declaration you muslprovide two siqned pasqpqrt photoqraphs for

every therapist empioyed, including any person who may only work pa.rt-time or provides

treatments as a seif-employed perion. This also includes persons working independently (e.9.

from a residential premiies) as 'Self-Employed. lf any current registered -therapist has sincechanged their name, home address or has icquired new licensable qualifications, sin@origiriaUy providing their Therapist Registration Form, then they are required to complete a newTnerapist Registration Form to be sent in with the application.

| /We hereby apply to the London Borough of Hounslow for the premises named in Section 2 of

this form to be liiensed for SpecialTreatnents under the above Act'

must be fully comoletedl

*Section l: Details of premises where special treatments will be conducted.TraOing name of premises to be licensed:

firrtI\ a\ N\c"' 0r\

Postcode: {V\ BT Business Telephone Number: 0'I0 5+lManager : , , , - ^ rLF"'d'i'ii r'l vVfr N t--loA N F- I'i\ i ri/ L{ Maiden NameSurname L) [ l\ rt*section 2: Perconal details of applicant

if"'Elli? r'r Yu&N l-1 Pf N ftsurname i l lNf- f

private

Maiden name

row Postc

*Section 3: Applicant declaration

I /We hereby declare that This application is true and is made knowing that if a licence is grantedor renewed, it may be revoked if anything has been wilfully stated in this application which I lWeknow to be false or do not believe to be true.

| / We have enclosed two identical fufl-face passport size photographs of each practitioner. Thenames of each practitioner have been written (capital letters) on the reverse.

I I We are aware of the Council's Special Treatment Licensing Policy & of its Standard Terms &Conditions and that it is available to read on the Council website for Massage & SpecialTreatments Licensing or can be requested from the Health & Safety Licensing Team.

| / We are aware the | / We are required to fully comply with the Standard Terms & Conditionsand failure to do so may result in My / Our licence being 'Suspended, Amended, Revoked orRefused at a future application as a result of the 'Delegated Officer' decision.

| /We have not been convicted of any offence under Part ll of the London LocalAuthorities Act1991.

I / We undertake to supply any other details as may be reasonably requested by the LondonBorough of Hounslow in connection with this application.

I I We will display at ALL times on the premises the licence where it can easily be read by thepublic. Or if requested by a member of the public to confirm that any person who is there toprovide a licensable treatment is a person named on the licence.

I I We have enclosed a revised plan of the premises as a result made to its layout or structuralchanges or additions made to the premises and | / We are aware that if we fail to provide anamended plan then any use of any part of the premises not registered on the original plan, willnot be authorised by the Councilto use for the purposes of providing treatments.

I I We enclose a cheque / postal order made payable to the London Borough of Hounslow forthe sum of € being the prescribed application fee.

| /We will be contacting the Council to make a payment by card.

Do not include with your application a payment in cash for your licence fee as the Council willnot accept any liability for its loss.

'^i ' Date: 4& q llSignatureofappl icant

'LU./4214

.. , _

Please return completed form to:London Borough of HounslowLicensingRegeneration, Economic Derclopment & EnvironmentCivic Centre, Lampton Road, Hounslow, Middlesex, TW3 4DNTelephone no. 020 8583 5555

Office use only

Cheque Amount & no.

Postal order Amount & no.

Receipt no

Date received:

London Boroughof Hounslow T.A.R.F 2016-2017

THERAPIST & APPRENTICE REGISTRATION FORM

London Local Authorities Act 1991 - Special Treatment Licence

This form is to be completed Onlv by those who wish to apply to be registered as a 'Therapist'

to provide licensable treatments Or have been taken on as an 'Apprentice' by the Licensee.

This form must be fully completed by All therapist / apprentices unless they completed thisregistration form previously and the information provided has remained the same. Failure toprovide all the details required on the form may result in your registration not being processedand therefore will prevent you from providing any licensable treatments.

lf you have previously completed this form and move to a new business in the London Boroughof Hounslow you are still required to complete this form. You should indicate where your lastplace of work as this will expedite your application as we will hold a record(s) of yourqualifications.

You should keep a copy of the completed registration form for your records. You may send thisform either through the 'Licensee' for the premises if that is not you, or directly to the Council asaddressed at the end of this form. You should ensure that you complete the registration formfully, othenruise it will not be processed and may prevent you from providing licensabletreatments in this authority.

The registration form remains confidential to the Health & Safety Special Treatment LicensingTeam and no information provided by you will be released to any other person without yourpermission.

You will receive an acknowledgement of being registered with the Council via a therapist cardbeing issued in your name. There maybe a delay in your card being issued due to theadministration process. You can though contact us either directly if you have an enquiry inregards to its issue status.

You must ensure that you list ALL treatments you will provide at the Licensed Premises You willreceive a 'Therapist / Apprentice Card' if the Council decides to register you. This therapist cardis non{ransferrable and cannot be used at anv other licensed premises or at your place ofresidence. You may only provide the licensable treatments for which the Council holds a copyof your qualification to practice.

Please use additional continuation form if required.lf you are completing this notice by hand please write legibly in block capitals. ln all casesensure that your answers are inside the boxes and written or typed in black ink.

You mav copv this form to complete all vour therapist / apprentice reoistrations.

lf you have any enquiry on completing this registration please contact one of the officers of theHealth & Safety Special Treatment Licensing Team on: 020 8583 5043 / 5035 / 5033.

London Boroughof Hounslow T.A.R.F 2016-2017

Please tick which registration you are applying for: Therapist ( ) Apprentice ( )

1. Your name VmFlTitle

Surname

Forenames

MiE| Mrs n Missn

PtoAt(Cf'-L[-tJoN q

Ms I Other (please state)

-2. previous names (Please enter details of any previous names or maiden

names, if they are different from those on your qualifications.

TitleSurnameForenames

Mrn Mrs n Missn Msn Other (please state)

3. Your date of birth4. Your place of birth5. National Insurance Numbero.\rour current address (We will use thiun|essVoucomp|etetheseparatecorreSpondencebM

7. Required lnformation

enotbeenprev ious|yreg is teredwi th th isauthor i tyto provide treatments or since your original registration you have added newtreatments that we do not hold information on you must include thisinformation on the continuation form for this registration. You can then providethe completed registration form and give it to the licensee for the premiseswho will complete the S.T.A.N.2 application and attach your information.you must provide the full address details and dates of the organisation (e.9.college / training establishment) where you undertook your training andprovide original qualifications when you register with the Council. You shouldalso ensure that when you submit qualifications e.g. Certificate / Diploma it isaccompanied with the Units / Modules you achieved to acquire thequalification. The Council will not accept as evidence of qualification, singleunits of achievements, you must hold a full level qualification. Please list thetreatments you will provide on the continuation form provided.trtame and address of the premises I will prqvide thesellgelrnen]g 3!

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Post code ^- ivr i r i NW'o'Sff'" Hlg l-g!4l

Applicant declaration :I herby declare that this application is true and is made knowing that if atherapist registration is granted to carry out Special Treatments as outlined inthe London Local Authorities Act 1991, it may be revoked if anything hasbeen wilfully stated in this application which I know to be false'Sisnature of applican,,

tul&>-Date: t l , ri "i

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London Boroughof Hounslow T.A.R.F 2016-2017

/Please tick which registration you are applying for: Therapist ('V)Apprentice ( )

1. The personal details of premises uqerff i iJANTitle

Surname

Forenames

Mrn Mrs I MissE

0r NHHonNq

Ms M Other (please state)

2. Previous names (Please enter details of any previous names or maidennames, if they are different from those on your qualifications.TitleSurnameForenames

Mrn Mrs n Missn MsE Other (please state)

3. Your date of birth Dav J .1 | Month O,J I Year / >L4. Your place of birth 8Ai croN5. National lnsurance Number NY tb z{ l t-}L

- i x6. Your current address (We will use this address to correspond with youunless vou complete the separate correspondence box below)

cil

Please note that if you have not been previously registered with this authorityto provide treatments or since your original registration you have added newtreatments that we do not hold information on you must include thisinformation on the continuation form for this registration. You can then providethe completed registration form and give it to the licensee for the premiseswho will complete the S.T.A.N.2 application and attach your information.You must provide the full address details and dates of the organisation (e.9.college / training establishment) where you undertook your training andprovide original qualifications when you register with the Council. You shouldalso ensure that when you submit qualifications e.g. Certificate / Diploma it isaccompanied with the Units / Modules you achieved to acquire thequalification. The Council will not accept as evidence of qualification, singleunits of achievements, you must hold a full level qualification. Please list thetreatments vou will provide on the continuation form provided.Name and address of the premises I will prov.ide these trea_tments a!

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':,\q"4KT'tse Bo IApplicant declaration :I herby declare that this application is true and is made knowing that if atherapist registration is granted to carry out Special Treatments as outlined inthe London Local Authorities Act 1991, it may be revoked if anything hasbeen wilfully stated in this application which I know to be false.Sisnature of applicant: \h/^M

Date: tE . q , 1 | ./

Manh Troung Hoanghas satisfied the requirements for the qualification

vrcT Level 2 NVQ Diploma in Nail Services(500/8840/3)

Assessed in the medium of V ie tnamese

Date: 10/0712016 Registration No: 1 183034

The award of this qualification is based on the successful attainment of the NationalStandards in units of competence as detailed on a Record of Achievement and/or

one of more Certificates of Unit Credit.

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Alan Woods OBEChief Executive

Registered in England and Wales number 2OSOO44Registered as a national charity in Great Britain number 2g5192

The regulatory logos on this certificate indicate the qualification is accredited for England and Wales.

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Manh Troung Hoanghas achieved the following unit(s)

(Assessed in the medium of Vietnamese)

Unit Title

Prepare and finish nail overlays using electric files

URN

Dt600n549

Date:1010712016

Level Credit Value

3 4

Registration No: 1 183034

A n ' n r J

@Alan Woods OBEChief Executive

EF!01220602-01-BLD3 990/00 1 20tD2fi978

Manh Troung Hoanghas achieved the following units from within the qualification

VTCT Level 2 NVQ Diploma in Nail Services(500/88 40t3)

Unit Title

Ensure responsibility for actions to reduce risks to health and safetyFulfil salon reception dutiesPromote additional services or products to customersDevelop and maintain effectiveness at workProvide manicure servicesProvide pedicure servicesCarry out nail art servicesApply and maintain nail enhancements to create a natural finish

43o36648

URN

A/601/5867Yt600t1264D/601/0936M/600/1268Yt600t7551H/600/8766A/600/8997L/600/9099

Date: 10/0712016

Level Credit Value

Registration No: 1{83034

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WAlan Woods OBEChief Executive

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