Section He-P 815.04 - Initial License Application Requirements(a) Each applicant for a license shall comply with the requirements of RSA 151:4II(a), I-I, and submit the following to the department: (1) A completed application form entitled "Application for Residential, Health Care License or Special Health Care Services" (February 2023), signed by the owner if a private facility, 2 officers if a corporation, 2 authorized individuals if an association or partnership, or the head of the government agency if a government unit affirming and certifying the following: "I affirm that I am familiar with the requirements of RSA 151 and the rules adopted thereunder and that the premises are in full compliance. I understand that providing false information shall be grounds for denial, suspension, or revocation of the license and the imposition of a fine.";
(2) A floor plan of the prospective ICF/IID;(3) If applicable, proof of authorization from the New Hampshire secretary of state to do business in New Hampshire in the form of one of the following: a. "Certificate of Authority," if a corporation;b. "Certificate of Formation," if a limited liability corporation; orc. "Certificate of Trade Name," if a sole proprietorship or if otherwise applicable;(4) The applicable fee in accordance with RSA 151:5, VI, payable in cash or, if paid by check or money order, the exact amount of the fee made payable to the "Treasurer, State of New Hampshire";(5) A resume identifying the name and qualifications of the ICF/IID administrator;(6) Copies of applicable licenses, certificates, or both for the ICF/IID administrator;(7) Written local approvals as follows: a. For an existing building, the following written local approvals shall be obtained no more than 90 days prior to submission of the application, from the following local officials, or if there is no such official(s), from the board of selectmen or mayor: 1. The health officer verifying that the applicant complies with all applicable local health requirements and drinking water and wastewater requirements;2. The building official verifying that the applicant complies with all applicable state building codes and local building ordinances;3. The zoning officer verifying that the applicant complies with all applicable local zoning ordinances; and4. The fire chief verifying that the applicant complies with the state fire code, RSA 153:1, VI-a, including the appropriate occupancy chapter of the life safety code 101 and the uniform fire code, NFPA 1, as published by the National Fire Protection Association (NFPA) and as amended by the state board of fire control and ratified by the general court pursuant to RSA 153:5, and local fire ordinances applicable for a health care facility; andb. For a building under construction, the written approvals required by a. above shall be submitted at the time of the application based on the local official's review of the building plans and upon completion of the construction project;(8) If the ICF/IID uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02, Env-Dw 704.02, or if a public water supply is used, a copy of a water bill;(9) The results of a criminal records check for the applicant(s), licensee if different than the applicant, medical director, and the administrator, as applicable;(10) A copy of the criminal attestation as described in He-P 815.17(m)(8) for the administrator and medical director;(11) If residents are adults, the results of a BEAS registry check from the bureau of elderly and adult services for the administrator and medical director; and(12) If residents are minors, the results of the DCYF central registry check of founded report of abuse and neglect for the administrator and medical director.(b) The applicant shall mail or hand-deliver the documents to: Department of Health and Human Services
Office of Legal and Regulatory Services
Health Facilities Administration
129 Pleasant Street
Concord, NH 03301
N.H. Admin. Code § He-P 815.04
Derived from Number 10, Filed March 9, 2023, Proposed by #13568, Effective 2/25/2023, Expires 2/25/2033.