APPLICATION FOR A PREMISES LICENCE TO BE GRANTEDUNDER THE LICENSING ACT 2003

Statement of the relevant licensable activities which it is proposed willbe carried on or from the premises:

Type: Retail of Alcohol.

Name of Applicant:Tesco Stores Ltd

Full postal address of premises:3,5,6,7 & 9 Station Approach, Sanderstead Road, South Croydon, CR2OPL

Postal address of local authority where register of applications is keptfor general viewing:London Borough of Croydon, Place Department, Licensing 6th FloorZone A, Bernard Weatherill House,8 Mint Walk, Croydon, CR0 lEA.Application details can be viewed at Access Croydon, BernardWeatherill House, between 9am - 3.45pm, Monday to Friday (exceptbank holidays)

If you wish to make any representations in relation to this application,please do so in writing by midnight on Wednesday 30th May 2018 tothe following address:

London Borough of CroydonPlace Department, Licensing Team,6th Floor, Zone ABernard Weatherill House8 Mint WalkCroydon, CR0 lEAOr By Email to: licensing@croydon.gov.uk

It is an offence to knowingly or recklessly make a false statement inconnection with an application. The maximum fine on summaryconviction for such an offence is £5000.

Application for a premises licence to be granted

under the Licensing Act 2003

PLEASE READ THE FOLLOWING INSTRUCTIONS FIRST

Before completing this form please read the guidance notes at the end of the form. If you arecompleting this form by hand please write legibly in block capitals. In all cases ensure that youranswers are inside the boxes and written in black ink. Use additional sheets if necessary.

You may wish to keep a copy of the completed form for your records.

IJWe Tesco Stores Ltd(Insert name(s) ofapplicant)

apply for a premises licence under section 17 of the Licensing Act 2003 for the premisesdescribed in Part 1 below (the premises) and IJwe are making this application to you as therelevant licensing authority in accordance with section 12 of the Licensing Act 2003

Part 1 — Premises details

Postal address of premises or, if none, ordnance survey map reference or description

Tesco Stores Ltd3,5,6,7 & 9 Station Approach,Sanderstead Road,

Post town South Croydon Postcode CR2 OPL

Telephone number at premises (if any)

Non-domestic rateable value of premises - IPart 2 - Applicant details

Please state whether you are applying for a premises licence as Please tick as appropriate

a) an individual or individuals * please complete section (A)

b) a person other than an individual *

i as a limited company/limited liability please complete section (B)partnership

ii as a partnership (other than limited please complete section (B)liability)

iii as an unincorporated association or please complete section (B)

iv other (for example a statutory corporation) please complete section (B)

c) a recognised club please complete section (B)

d) a charity LI please complete section (B)

e) the proprietor of an educational establishment LI please complete section (B)

f) a health service body LI please complete section (B)

g) a person who is registered under Part 2 of the LI please complete section (B)Care Standards Act 2000 (c14) in respect of anindependent hospital in Wales

ga) a person who is registered under Chapter 2 of LI please complete section (B)Part I of the Health and Social Care Act 2008(within the meaning of that Part) in anindependent hospital in England

h) the chief officer of police of a police force in LI please complete section (B)England and Wales

* If you are applying as a person described in (a) or (b) please confirm (by ticking yes to onebox below):

I am carrying on or proposing to carry on a business which involves the use of thepremises for licensable activities; or

I am making the application pursuant to a

statutory function or LIa function discharged by virtue of Her Majesty’s prerogative LI

(A) INDIVIDUAL APPLICANTS (fill in as applicable)

Mr LI Mrs LI Miss LI Ms LI Other Title (for

Surname First names

Date of birth I am 18 years old orPlease tick yesover

Nationality

Current residentialaddress if different frompremises address

Post town Postcode

Daytime contact telephone number

E-mail address(optional)

SECOND INDIVIDUAL APPLICANT (if applicable)

Mr El Mrs [1 Miss [1 MsOther Title (for

Surname First names

Date of birth I am 1 8 years old orPlease tick yesover

Nationality

Current residentialaddress if different frompremises address

Post town Postcode

Daytime contact telephone number

E-mail address(optional)

(B) OTHER APPLICANTS

Please provide name and registered address of applicant in full. Where appropriate pleasegive any registered number. In the case of a partnership or other joint venture (other than abody corporate), please give the name and address of each party concerned.

NameTesco Stores Ltd

Address

Registered number (where applicable)

Description of applicant (for example, partnership, company, unincorporated association etc.)Limited Company

Telenhone number (if any)

E-mail address (optional)

Part 3 Operating Schedule

When do you want the premises licence to start? As soon as possible

If you wish the licence to be valid only for a limited period,when do you want it to end?

DD MM YYYY

If 5.000 or more people are expected to attend the premises at anyone time, please state the number expected to attend.

What licensable activities do you intend to carry on from the premises?

(Please see sections 1 and 14 and Schedules I and 2 to the Licensing Act 2003)

Provision of regulated entertainment (please read guidance note 2)

a) plays (if ticking yes, fill in box A)

b) films (if ticking yes, fill in box B)

c) indoor sporting events (if ticking yes, fill in box C)

d) boxing or wrestling entertainment (if ticking yes, fill in box D)

e) live music (if ticking yes, fill in box E)

f) recorded music (if ticking yes, fill in box F)

g) performances of dance (if ticking yes, fill in box G)

hanything of a similar description to that falling within (e), (0 or (g)

‘ (if ticking yes, fill in box H)

Please give a general description of the premises (please read guidance note I)

Retail premises (supermarket) selling a range of goods and services. This includes thesale of alcohol for consumption off the premises. Sales of alcohol for consumption off thepremises are made from the supermarket sales floor as shown on the enclosed plan

N/A

Please tick all thatapply

LI

Provision of late night refreshment (if ticking yes, fill in box I)

Supply of alcohol (if ticking yes, fill in box J)

In all cases complete boxes K L and M

A

Will the performance of a play take placeindoors or outdoors or both — please tick(please read guidance note 3)

PlaysStandard days andtimings (please readguidance note 7)

indoors

Outdoors D

Please give further details here (please read guidance note 4)

Both

State any seasonal variations for performing plays (please readguidance note 5)

Non standard timings. Where you intend to use the premisesfor the performance of plays at different times to those listed inthe column on the left, please list (please read guidance note 6)

B

Films Will the exhibition of films take placeStandard days and indoors or outdoors or both

— please tick Indoors LItimings (please read (please read guidance note 3)guidance note 7) Outdoors

Day Start Finish Both [1Mon Please give further details here (please read guidance note 4)

Tue

Wed State any seasonal variations for the exhibition of films (pleaseread guidance note 5)

Thur

Fri Non standard timings. Where you intend to use the premisesfor the exhibition of films at different times to those listed in thecolumn on the left, please list (please read guidance note 6)

Sat

Sun

C

Indoor sporting events Please give further details (please read guidance note 4)Standard days andtimings (please readguidance note 7)

Day Start Finish

Mon

Tue State any seasonal variations for indoor sporting events (please. read guidance note 5)

Wed

Thur Non standard timings. Where you intend to use the premisesfor indoor sporting events at different times to those listed in thecolumn on the left, please list (please read guidance note 6)

Fri

Sat

S un

D

Boxing or wrestling Will the boxing or wrestling entertainment —

entertainments take place indoors or outdoors or both — Indoors

Standard days and please tick (please read guidance note 3)timings (please read

Outdoorsguidance note 7)

Day Start Finish Both

Mon Please give further details here (please read guidance note 4)

Tue

Wed State any seasonal variations for boxing or wrestlingentertainment (please read guidance note 5)

Thur

Fri Non standard timings. Where you intend to use the premisesfor boxing or wrestling entertainment at different times to thoselisted in the column on the left, please list (please read guidance

Sat note 6)

Sun

E

Live music Will the performance of live music take placeStandard days and indoors or outdoors or both — please tick Indoors

timings (please read (please read guidance note 3)guidance note 7) Outdoors LI

Day Start Finish Both LIMon Please give further details here (please read guidance note 4)

Tue

Wed State any seasonal variations for the performance of live music(please read guidance note 5)

Thur

Fri Non standard timings. Where you intend to use the premisesfor the performance of live music at different times to thoselisted in the column on the left, please list (please read guidance

Sat note 6)

Sun

F

Recorded musicStandard days andtimings (please readguidance note 7)

Will the playing of recorded music take placeindoors or outdoors or both — please tick(please read guidance note 3)

Please give further details here (please read guidance note 4)

State any seasonal variations for the playing of recorded music(please read guidance note 5)

Non standard timings. Where you intend to use the premisesfor the playing of recorded music at different times to thoselisted in the column on the left, please list (please read guidance

Indoors

Outdoors D

Both

note 6)

G

Performances of Will the performance of dance take placedance indoors or outdoors or both — please tick Indoors

Standard days and (please read guidance note 3)timings (please read Outdoorsguidance note 7)

Day Start Finish Both

Mon Please give further details here (please read guidance note 4)

Tue

Wed State any seasonal variations for the performance of dance(please read guidance note 5)

Thur

Fri Non standard timings. Where you intend to use the premisesfor the performance of dance at different times to those listed inthe column on the left, please list (please read guidance note 6)

Sat

Sun

H

Anything of a similar Please give a description of the type of entertainment you will bedescription to that providingfalling within (e), (0 or(g)Standard days andtimings (please readguidance note 7)

Day Start Finish Will this entertainment take place indoors or Indoorsoutdoors or both — please tick (please read

Mon guidance note 3) Outdoors D

Both

Tue Please give further details here (please read guidance note 4)

Wed

Thur State any seasonal variations for entertainment of a similardescription to that falling within (e), (0 or () (please readguidance note 5)

Fri

Sat Non standard timings. Where you intend to use the premisesfor the entertainment of a similar description to that fallingwithin (e), (fl or (g) at different times to those listed in thecolumn on the left, please list (please read guidance note 6)

Sun

I

Will the provision of late night refreshmenttake place indoors or outdoors or both —

please tick (please read guidance note 3)

Outdoors D

State any seasonal variations for the provision of late nightrefreshment (please read guidance note 5)

Non standard timings. Where you intend to use the premisesfor the provision of late night refreshment at different times, tothose listed in the column on the left, please list (please read

Late nightrefreshmentStandard days andtimings (please readguidance note 7’

Indoors

Please give further details here (please read guidance note 4)

Both

guidance note 6)

J

Supply of alcohol Will the supply of alcohol be for On the —

Standard days and consumption — please tick (please read premisestimings (please read guidance note 8)guidance note 7) Off the

premises

Day Start Finish Both

Mon 06:00 23:00 State any seasonal variations for the supply of alcohol (pleaseread guidance note 5)

Tue 06:00 23:00

Wed 06:00 23:00

Thur 06:00 23:00 Non standard timings. Where you intend to use the premisesfor the supply of alcohol at different times to those listed in thecolumn on the left, please list (please read guidance note 6)

Fri 06:00 23:00

Sat 06:00 23:00

Sun 06:00 23:00

State the name and details of the individual whom you wish to specify on the licence asdesignated premises supervisor (Please see declaration about the entitlement to work in thechecklist at the end of the form):

Name: Steven Nicholas Andrzejuk

Date of birtk.

Address:

Postcode

Personal licence number:

Issuing licensing authority:

mm

K

L

Day Start Finish

Mon 06:00 23:00

Tue 06:00 23:00

Thur 06:00 23:00

Fri 06:00 23:00

Sat 06:00 23:00

Please highlight any adult entertainment or services, activities, other entertainment ormatters ancillary to the use of the premises that may give rise to concern in respect ofchildren (please read guidance note 9).

Hours premises areopen to the publicStandard days andtimings (please readguidance note 7)

State any seasonal variations (please read guidance note 5)

Wed 06:00 23:00

Non standard timings. Where you intend the premises to beopen to the public at different times from those listed in thecolumn on the left, please list (please read guidance note 6)

Sun 06:00 23:00

M Describe the steps you intend to take to promote the four licensing objectives:

a) General — all four licensing objectives (b, c, d and e) (please read guidance note 10)

Tesco is a large national operator with a range of head office and local support.The company has devised policies, procedures, systems and training to ensurethat they sell alcohol in a responsible manner.

There is a detailed training programme which ensures that comprehensive trainingis provided to employees having regard to their role and the responsibilities andsuch training is regularly reviewed and appropriate records kept.

b) The prevention of crime and disorder

The premises will have digital CCTV system that covers many areas of the shopfloor, including the main area which will be used for display of alcohol,Images will be retained for a minimum of 21 daysA member of the Management team will ordinarily be on the premises all the timethe store is open and person will have responsibility for the premises whilst thepremises are open.

c) Public safety

The premises licence holder is fully aware of its responsibilities under a range ofhealth and safety related legislation and has appropriate policies and proceduresin place to be confident of complying with the relevant obligations which arise.

d) The prevention of public nuisance

The company has a “good neighbour” policy which seeks to ensure that thepremises play an active part in the local community.

e) The protection of children from harm

The premises will operate a Think 25 policy. The checkouts will be programmedto prompt the checkout assistant when an alcohol product is scanned at the till tofollow the Think 25 policy.

Colleagues will receive appropriate training both in relation to the underlying lawand the Tesco policy, systems and procedures. This training will be documentedand repeated as often as Tesco believes to be appropriate.

Checklist:

Please tick to indicate agreement

• (have made or enclosed payment of the fee.• have enclosed the plan of the premises.

• I have sent copies of this application and the plan to responsible authorities andothers where applicable.

• (have enclosed the consent form completed by the individual I wish to bedesignated premises supervisor, if applicable.

• understand that I must now advertise my application.

• I understand that if I do not comply with the above requirements my application willbe rejected.

.

[Applicable to all individual applicants, including those in a partnership which is nota limited liability partnership, but not companies or limited liability partnerships] Ihave included documents demonstrating my entitlement to work in the UnitedKingdom (please read note 15).

iT IS AN OFFENCE, UNDER SECTION 158 OF THE LICENSING ACT 2003, TO MAKEA FALSE STATEMENT IN OR IN CONNECTION WITH THIS APPLICATION. THOSEWHO MAKE A FALSE STATEMENT MAY BE LIABLE ON SUMMARY CONVICTIONTO A FINE OF ANY AMOUNT.

IT IS AN OFFENCE UNDER SECTION 24B OF THE IMMIGRATION ACT 1971 FOR APERSON TO WORK WHEN THEY KNOW, OR HAVE REASONABLE CAUSE TOBELIEVE, THAT THEY ARE DISQUALIFIED FROM DOING SO BY REASON OFTHEIR IMMIGRATION STATUS. THOSE WHO EMPLOY AN ADULT WITHOUTLEAVE OR WHO IS SUBJECT TO CONDITIONS AS TO EMPLOYMENT WILL BELIABLE TO A CIVIL PENALTY UNDER SECTION 15 OF THE IMMIGRATION,ASYLUM AND NATIONALITY ACT 2006 AND PURSUANT TO SECTION 21 OF THESAME ACT, WILL BE COMMITTING AN OFFENCE WHERE THEY DO SO IN THEKNOWLEDGE, OR WITH REASONABLE CAUSE TO BELIEVE, THAT THEEMPLOYEE IS DISQUALIFIED.

Part 4 — Signatures (please read guidance note 11)

Signature of applicant or applicant’s solicitor or other duly authorised agent (see guidancenote 12). If signing on behalf of the applicant, please state in what capacity.

. [Applicable to individual applicants only, including those in apartnership which is not a limited liability partnership] I understand Iam not entitled to be issued with a licence if I do not have theentitlement to live and work in the UK (or if I am subject to acondition preventing me from doing work relating to the carrying on

Declaration of a licensable activity) and that my licence will become invalid if Icease to be entitled to live and work in the UK (please read guidancenote 15).

• The DPS named in this application form is entitled to work in the UK(and is not subject to conditions preventing him or her from doing

work relating to a licensable activity) and I have seen a copy of his orher proof of entitlement to work, if appropriate (please see note 15)

Signature

Date 30/04/2018

Capacity Steven Andrzejuk - I

For joint applications, signature of 2m1 applicant or 21 applicant’s solicitor or otherauthorised agent (please read guidance note 13). If signing on behalf of the applicant, pleasestate in what capacity.

Signature

Date

Capacity

Contact name (where not previously given) and postal address for correspondence associatedwith this application (please read guidance note 14)

Post town - Postcode

Telephone number (if any)

If you would prefer us to correspond with you by e-mail, your e-mail address (optional)

of

Home Address:

hereby confirm that I give my consent to be specified as the designated premises supervisor in relation tothe application for varying a premises licence to specify an individual as designated premises supervisorunder section 37 of the Licensing Act 2003 by Tesco Stores Ltd relating to a premises licence:

Tesco Stores Ltd

for

Store Number:Store Address:

3,5,6,7 & 9 Station Approach,Sanderstead Road,South CroydonCR2 OPL

and any premises licence to be granted or varied in respect of the application made by Tesco Stores Ltdconcerning the supply of alcohol at the above premises.

I also confirm that I am entitled to work in the United Kingdom and am applying for, intend to apply for orcurrently hold a personal licence, details of which I set out below.

Personal licence number

Personal Licence issuing authority

Signed

Name (Please Print)

ESteven Andrzejuk

Full Name: Steven Nicholas Andrzejuk

Date of Birth:

Place of Birth

Nationality:

Employee Number: