Section Ph 601.03 - Application Contents(a) The applicant for licensure shall complete and submit a "Limited Retail Drug Distributor of Medical Gases and/or Medical Devices" form, form MM-1, revised June 2017.(b) The applicant shall also submit the following:(1) A scaled drawing of the facility;(2) A copy of the state license from the state licensing agency where the facility is located, if such facility is outside New Hampshire, or an explanation detailing why the applicant does not have such a license; and(3) A copy of the facility's most recent inspection report completed by the state licensing board or agency where the facility is domiciled, if it is located outside New Hampshire, or an explanation detailing why the applicant does not have such an inspection report.(c) The applicant shall supplement the application specified in (a) and (b) above with any certificates, affidavits, plans, documents or other information sufficient to show full compliance with all of the requirements of Ph 600.(d) If the applicant is a corporation, or the limited retail drug distributor will be operated under a corporate name, a certificate from the NH secretary of state attesting to the documents creating the corporate person and any amendment(s) thereof to the certificate of incorporation, or authorizing it to do business in the state of New Hampshire under the corporate name shall be included with the application.(e) If the applicant proposes to hold, store, or dispense controlled substances as a methadone maintenance/detoxification facility, the application shall be supplemented with the following information: (1) A brief description of the security system;(2) A list of all persons with access to the controlled substances;(3) The applicant shall supplement the application specified in (a) above with any certificates, affidavits, plans, documents or other information sufficient to show full compliance with all of the requirements for operation of a drug abuse treatment facility, as outlined in He-A 304; and(4) If the application is for a methadone maintenance/detoxification facility, the applicant shall submit the current registration number issued by the federal drug enforcement administration (DEA).(f) The applicant shall sign, indicate his or her title, and date the application under the following affirmation: "I affirm that I am the person authorized to sign this application for licensure and declare under penalties of unsworn falsification under RSA 641:3 that this application (including any accompanying documents) has been examined by me and to the best of my knowledge and belief is a true, correct and complete application, and if the registration herein applied for is granted, I hereby agree to and do submit to the jurisdiction of the New Hampshire board of pharmacy and to the laws and rules of this state."
(g) The board shall issue a license pursuant to this section if the applicant: (1) Files a complete application that meets the requirements of these rules and RSA 318; and(2) Is of good moral character, or, if the applicant is an association or corporation, that the managing officers are of good moral character, as evidenced by the absence, within the last 5 years, of conviction of any felony, or of a misdemeanor resulting from a violation of any drug related law of the United States or of any state.N.H. Admin. Code § Ph 601.03
Amended by Volume XXXVII Number 32, Filed August 10, 2017, Proposed by #12335, Effective 7/22/2017, Expires 7/22/2027.