FEHB 178.doc

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1 申請更改卡拉 OK 場所名稱 APPLICATION FOR CHANGE OF NAME OF KARAOKE ESTABLISHMENT ( 填寫申請書前請參閱附連的申請人須知 ) (Please read the Notice to Applicant attached before completing your application form) 致 : 分區辦事處秘書 To : District Secretary 本人欲就下述處所申請更改卡拉 OK 場所名稱 I intend to apply for the change of name of the karaoke establishment in respect of the premises mentioned below. ( 倘以公司或合夥名義提出申請, 請於乙段或丙段提供所需的補充資料 ) (If application is made in the name of a corporation or partnership, please provide additional information required in Section B or C below where appropriate.) ( 甲 ) 申請資料 (A) Particulars of Application (1) 持證人姓名 :( 中文 ) ( 英文 ) ( 先生 / 女士 *) Name of Grantee (Chinese) (English) (Mr./Ms*) (2) 香港身分證 / 護照 * 號碼 : Hong Kong Identity Card/Passport* No. (3) 住址 : Residential Address (4) 電話號碼 : 傳真號碼 : Tel. No. Fax No. (5) 現行卡拉 OK 場所名稱 ( 中文 ): Existing Name of the Karaoke Establishment (Chinese) ( 英文 ): (English) (6) 建議卡拉 OK 場所名稱 ( 中文 ): Proposed Name of the Karaoke Establishment (Chinese) ( 英文 ): (English) (7) 現時有效許可證號碼 : Current Valid Permit No. 1

( 倘以公司或合夥名義提出申請, 請於乙段或丙段提供所需的補充資料 ) (If application is made in the name of a corporation or partnership, please provide additional information required in Section B or C

2 (8) 卡拉 OK 場所地址 : Address of the Karaoke Establishment 室 / 鋪樓座 Flat/Rm/Shop Floor Block 大廈 Building 屋邨 / 鄉村 Estate/Village 街道名稱及號碼 No. and Name of Road/Street 如涉及多於一條街道, 請詳述 (if more than one road/street is involved, please specify) 分區 Sub-District 地區 District 地段號碼 ( 如適用 ) 香港九龍新界離島 Lot Number (if any) HK Kln NT Islands (9) 卡拉 OK 場所電話號碼 : 卡拉 OK 場所傳真號碼 : Tel. No. of the Karaoke Establishment Fax No. of the Karaoke Establishment (10) 本人以中文 / 英文 * 為日後的通訊語言 I would use Chinese/English* for my future correspondence. 2

段號碼 ( 如適用 ) 香港九龍新界離島 Lot Number (if any) HK Kln NT Islands (9) 卡拉 OK 場所電話號碼 : 卡拉 OK 場所傳真號碼 : Tel. No.

3 ( 乙 ) 公司的獲授權代表資料 (B) Particulars of the Authorised Representative of the Corporation (1) 獲授權代表姓名 :( 中文 ) ( 英文 ) ( 先生 / 女士 *) Name of the Authorised Representative (Chinese) (English) (Mr./Ms.*) (2) 香港身分證 / 護照 * 號碼 : Hong Kong Identity Card/Passport* No. (3) 獲授權代表在公司擔任的職位 : Position of the Authorised Representative in the Corporation (4) 住址 : Residential Address (5) 電話號碼 : 傳真號碼 : Tel. No. Fax No. ( 丙 ) 合夥的獲授權代表資料 (C) Particulars of the Authorised Representative of the Partnership (1) 獲授權代表姓名 :( 中文 ) ( 英文 ) ( 先生 / 女士 *) Name of the Authorised Representative (Chinese) (English) (Mr./Ms.*) (2) 香港身分證 / 護照 * 號碼 : Hong Kong Identity Card/Passport* No. (3) 獲授權代表在合夥擔任的職位 : Position of the Authorised Representative in the Partnership (4) 住址 : Residential Address (5) 電話號碼 : 傳真號碼 : Tel. No. Fax No. 持證人簽署 Signature of Grantee 獲授權代表簽署 Signature of Authorised Representative ( 代表申請公司 / 合夥 *) (for and on behalf of the applying corporation/partnership*) 日期 ( 日 / 月 / 年 ) 公司印章 ( 只限申請公司 ) Date (dd/mm/yyyy) Company Chop (for applying corporation only) 3

(3) 獲授權代表在公司擔任的職位 : Position of the Authorised Representative in the Corporation (4) 住址 : Residential Address (5) 電話號碼 : 傳真號碼 : Tel. No. Fax No.

4 警告 WARNING 根據卡拉 OK 場所條例 ( 第 573 章 ) 的規定, 任何人知道或理應知道陳述 ( 不論是口頭陳述或書面陳述 ) 或資料在要項上失實, 但仍在本申請的過程中, 或在與本申請有關連的情況下, 作出或提交該等在要項上失實的陳述或資料, 即屬違法, 如屬首次定罪, 可被判罰款 50,000 元及監禁 6 個月 Any person who in or in connection with this application makes any statement or furnishes any information (whether such statement be oral or written), which is false in any material particular and which he knows or reasonably ought to know is false in any such particular commits an offence and is liable on first conviction to a fine of $50,000 and to imprisonment for 6 months under the Karaoke Establishments Ordinance (Cap. 573) * 請刪去不適用者 Please delete where appropriate. 請在適當的方格內填上號 Please tick the appropriate box(es). 4

or written), which is false in any material particular and which he knows or reasonably ought to know is false in any such particular commits an offence and is liable on first conviction to a fine of

5 申請人須知 NOTICE TO APPLICANT 1. 卡拉 OK 場所條例 ( 第 17(1)(c)) 條規定, 任何人以許可證所示明的卡拉 OK 場所名稱以外的名稱經營料理管理或以其他方式控制該場所, 即屬犯罪 Section 17(1)(c) of the Karaoke Establishments Ordinance (Cap. 573) provides that any person who operates, keeps, manages or otherwise has control of a karaoke establishment under any name other than the name of the karaoke establishment indicated in the permit commits an offence. 2. 持證人如欲把其卡拉 OK 場所名稱由許可證所示明的名稱更改為其他名稱, 須向食物環境衞生署有關的分區辦事處秘書申請把新名稱簽註在許可證上 Grantees have to apply to the District Secretary concerned of the Food and Environmental Hygiene Department for endorsement of a change of name in the permit if they intend to change the name of their karaoke establishment from the one indicated in the permit to other name. 3. 由收到卡拉 OK 場所更改名稱申請到原則上予以批准, 一般需時 14 天 The time for granting an approval-in-principle for change of name of a karaoke establishment will be 14 days from the date of receipt of such an application under normal circumstances. 4. 有關的分區辦事處秘書會安排約見持證人, 以便把卡拉 OK 場所的新名稱簽註在許可證上, 但持證人須遞交下列文件 : District Secretary concerned will arrange an appointment with the grantee for endorsing the new name of the karaoke establishment onto the permit provided that the grantee can submit the following documents : (i) 可以看到卡拉 OK 場所新名稱的相片, 例如場所的招牌 ; 以及 a photo showing the shop signs, etc. of the karaoke establishment with the new name; and (ii) 由公司註冊處處長證實的商業登記認證副本, 並列有卡拉 OK 場所的新名稱 a certified true copy of Business Registration Certificate showing the new name of the karaoke establishment. 5. 申請人亦可在政府表格網頁 : 以電子形式提交申請, 並須一併以電子形式提交有關文件 Applicant may also submit electronic applications together with the relevant documents via Government Forms website : 5

573) provides that any person who operates, keeps, manages or otherwise has control of a karaoke establishment under any name other than the name of the karaoke establishment indicated in the permit

6 1. 收集資料的目的 Purposes of Collection 關於申請更改卡拉 OK 場所名稱所填報的個人資料 Collection of Personal Data in Connection with Application for Change of Name of Karaoke Establishment ( 按照個人資料 ( 私隱 ) 條例的規定處理 ) (In accordance with the Personal Data (Privacy) Ordinance) 目的說明 Statement of Purpose 你透過本申請表格所提供的個人資料, 會供食物環境衞生署 ( 食環署 ) 分區環境衞生辦事處用於下述目的 : The personal data provided by means of this form will be used by the District Environmental Hygiene Office of the Food and Environmental Hygiene Department (FEHD) for : (1) 處理向食環署牌照組 / 分區環境衞生辦事處提交的新簽發 / 轉讓 / 續發卡拉 OK 場所許可證 / 臨時卡拉 OK 場所許可證或豁免申請卡拉 OK 場所許可證 / 臨時卡拉 OK 場所許可證或更改卡拉 OK 場所名稱申請的相關事宜 ; 以及 carrying out activities relating to the applications for the grant/transfer/renewal of Karaoke Establishment Permit/Provisional Karaoke Establishment Permit or the exemption to apply for a Karaoke Establishment Permit/Provisional Karaoke Establishment Permit or the change of name of a karaoke establishment made to the Licensing Section/District Environmental Hygiene Office of the FEHD; and (2) 方便食環署職員及其他政府部門的職員與你之間的聯絡 facilitating communication among staff of the FEHD, other Government departments and yourself. 你透過本申請表格提供個人資料, 純屬自願不過, 如你不提供充分的資料, 則食環署恐怕不能處理你的申請 The provision of personal data by means of this form is voluntary. However, if you do not provide sufficient information, the FEHD may not be able to process your application. 2. 接受資料轉介人的類別 Class of Transferees 食環署可能會向其他政府部門及機構披露你透過本申請表格所提供的資料, 以達到上文第 1 段所述的目的 The personal data which you have provided by means of this form may be disclosed to other Government departments and agencies in pursuance of the purposes mentioned in paragraph 1 above. 3. 查閱個人資料 Access to Personal Data 根據個人資料 ( 私隱 ) 條例第 18 條第 22 條及附表 1 第 6 原則的規定, 你有權要求查閱及改正所提供的個人資料查閱的權利包括有權索取本申請表格所提供的個人資料的複本一份食環署應查閱要求而提供資料時, 可能徵收費用 You have a right to request access to and correction of the personal data provided in accordance with Sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. Your right of access includes the right to obtain a copy of your personal data which you have provided by means of this form. A fee may be imposed for complying with a data access request. 6

目的 : The personal data provided by means of this form will be used by the District Environmental Hygiene Office of the Food and Environmental Hygiene Department (FEHD) for : (1) 處理向食環署牌照組 /

7 4. 查詢 Enquiries 如對本申請表格收集的個人資料有任何查詢, 包括查閱及更改資料等, 可向下列人士提出 : Enquiries concerning the personal data collected by means of this form, including the making of access and corrections, should be addressed to : 港島區及離島區中西區環境衞生辦事處香港皇后大道中 345 號上環市政大廈 10 樓電話號碼 : 傳真號碼 : 東區環境衞生辦事處香港魚涌街 38 號魚涌市政大廈 3 樓電話號碼 : 傳真號碼 : 南區環境衞生辦事處香港香港仔大道 203 號香港仔市政大廈 4 樓電話號碼 : 傳真號碼 : 灣仔區環境衞生辦事處香港灣仔軒尼詩道 225 號駱克道市政大廈 7 樓電話號碼 : 傳真號碼 : 離島區環境衞生辦事處香港中環統一碼頭道 38 號海港政府大樓 6 樓電話號碼 : 傳真號碼 : Hong Kong & Islands Central/Western District Environmental Hygiene Office 10/F, Sheung Wan Municipal Services Building, 345 Queen s Road Central, Hong Kong Tel. no.: Fax no.: Eastern District Environmental Hygiene Office 3/F, Quarry Bay Municipal Services Building, 38 Quarry Bay Street, Hong Kong Tel. no.: Fax no.: Southern District Environmental Hygiene Office 4/F, Aberdeen Municipal Services Building, 203 Aberdeen Main Road, Hong Kong Tel. no.: Fax no.: Wanchai District Environmental Hygiene Office 7/F, Lockhart Road Municipal Services Building, 225 Hennessy Road, Wanchai, Hong Kong Tel. no.: Fax no.: Islands District Environmental Hygiene Office 6/F, Harbour Building, 38 Pier Road, Central, Hong Kong Tel. no.: Fax no.: 九龍區九龍城區環境衞生辦事處九龍馬頭圍道 165 號土瓜灣政府合署 3 樓及 4 樓電話號碼 : 傳真號碼 : 觀塘區環境衞生辦事處九龍觀塘瑞和街 9 號瑞和街市政大廈 7 樓電話號碼 : 傳真號碼 : 旺角區環境衞生辦事處九龍旺角花園街 123 號 A 花園街市政大廈 6 樓及 7 樓電話號碼 : 傳真號碼 : 深水埗區環境衞生辦事處九龍深水埗元州街號元州街市政大廈 8 樓至 10 樓電話號碼 : 傳真號碼 : 黃大仙區環境衞生辦事處九龍黃大仙彩虹道 121 號大成街街市大樓 3 樓電話號碼 : 傳真號碼 : 油尖區環境衞生辦事處九龍油麻地寶靈街 17 號官涌市政大廈 3 樓及 4 樓電話號碼 : 傳真號碼 : Kowloon Kowloon City District Environmental Hygiene Office 3/F & 4/F, To Kwa Wan Market and Government Offices, 165 Ma Tau Wai Road, Kowloon Tel. no.: Fax no.: Kwun Tong District Environmental Hygiene Office Level 7, Shui Wo Street Municipal Services Building, 9 Shui Wo Street, Kwun Tong, Kowloon Tel. no.: Fax no.: Mong Kok District Environmental Hygiene Office 6/F & 7/F, Fa Yuen Street Municipal Services Building, 123A Fa Yuen Street, Mong Kok, Kowloon Tel. no.: Fax no.: Sham Shui Po District Environmental Hygiene Office 8/F-10/F, Un Chau Street Municipal Services Building, Un Chau Street, Sham Shui Po, Kowloon Tel. no.: Fax no.: Wong Tai Sin District Environmental Hygiene Office 3/F, Tai Shing Street Market Building, 121 Choi Hung Road, Wong Tai Sin, Kowloon Tel. no.: Fax no.: Yau Tsim District Environmental Hygiene Office 3/F & 4/F, Kwun Chung Municipal Services Building, 17 Bowring Street, Yau Ma Tei, Kowloon Tel. no.: Fax no.:

電話號碼 :3103 7041 傳真號碼 :2565 8203 南區環境衞生辦事處香港香港仔大道 203 號香港仔市政大廈 4 樓電話號碼 :2903 0411 傳真號碼 :2873 1608 灣仔區環境衞生辦事處香港灣仔軒尼詩道 225 號駱克道市政大廈 7 樓電話號碼

8 新界區沙田區環境衞生辦事處新界沙田鄉事會路 138 號新城市中央廣場第 1 座 12 樓室及室電話號碼 : 傳真號碼 : 大埔區環境衞生辦事處新界大埔鄉事會街 8 號大埔綜合大樓 3 樓電話號碼 : 傳真號碼 : 北區環境衞生辦事處新界上水智昌路 13 號石湖墟市政大廈 4 樓電話號碼 : 傳真號碼 : 西貢區環境衞生辦事處新界將軍澳培成路 38 號西貢將軍澳政府綜合大樓 8 樓電話號碼 : 傳真號碼 : 葵青區環境衞生辦事處新界葵涌興芳路號葵興政府合署 9 樓電話號碼 : 傳真號碼 : 荃灣區環境衞生辦事處新界荃灣楊屋道 45 號楊屋道市政大廈 3 樓電話號碼 : 傳真號碼 : 屯門區環境衞生辦事處新界屯門屯喜路 1 號屯門政府合署 1 樓及 3 樓電話號碼 : 傳真號碼 : 元朗區環境衞生辦事處新界元朗橋樂坊 2 號元朗政府合署 2 樓至 5 樓電話號碼 : 傳真號碼 : New Territories Sha Tin District Environmental Hygiene Office Unit , , 12/F, Tower 1, Grand Central Plaza, 138 Rural Committee Road, Sha Tin, New Territories Tel. no.: Fax no.: Tai Po District Environmental Hygiene Office 3/F, Tai Po Complex, 8 Heung Sze Wui Street, Tai Po, New Territories Tel. no.: Fax no.: North District Environmental Hygiene Office 4/F, Shek Wu Hui Municipal Services Building, 13 Chi Cheong Road, Sheung Shui, New Territories Tel. no.: Fax no.: Sai Kung District Environmental Hygiene Office 8/F, Sai Kung Tseung Kwan O Government Complex, 38 Pui Shing Road, Tseung Kwan O, New Territories Tel. no.: Fax no.: Kwai Tsing District Environmental Hygiene Office 9/F, Kwai Hing Government Offices Building, Hing Fong Road, Kwai Chung, New Territories Tel. no.: Fax no.: Tsuen Wan District Environmental Hygiene Office 3/F, Yeung Uk Road Municipal Services Building, 45 Yeung Uk Road, Tsuen Wan, New Territories Tel. no.: Fax no.: Tuen Mun District Environmental Hygiene Office 1/F & 3/F, Tuen Mun Government Offices Building, 1 Tuen Hi Road, Tuen Mun, New Territories Tel. no.: Fax no.: Yuen Long District Environmental Hygiene Office 2/F-5/F, Yuen Long Government Offices, 2 Kiu Lok Square, Yuen Long, New Territories Tel. no.: Fax no.:

:3740 5100 傳真號碼 :2792 9937 葵青區環境衞生辦事處新界葵涌興芳路 166-174 號葵興政府合署 9 樓電話號碼 :2619 9482 傳真號碼 :2480 4023 荃灣區環境衞生辦事處新界荃灣楊屋道 45 號楊屋道市政大廈 3 樓電話號碼 :2212

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