1. (a) Each applicant for a license shall comply with the requirements of RSA 151:4, I–III-a and submit the following to the department:

   1. (1) A completed application form entitled “Application for Residential, Health Care, or Special Health Care Services” (August 2025), signed by the owner if a private entity, 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 to 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. (2) A floor plan of the prospective SRHCF indicating the location of all rooms, number of beds in each bedroom, and fire exits;

   3. (3) If applicable, proof of authorization from the New Hampshire secretary of state to do business in the state of New Hampshire in the form of one of the following:

      1. a. “Certificate of Authority,” if a corporation;
      2. b. “Certificate of Formation,” if a limited liability corporation; or
      3. c. “Certificate of Trade Name,” where applicable;
   4. (4) The applicable fee in accordance with RSA 151:5, IX, payable in cash or, if paid by check or money order, in the exact amount of the fee made payable to the “Treasurer, State of New Hampshire”;
   5. (5) A resume identifying the qualifications of the SRHCF administrator and medical director, if applicable;
   6. (6) Copies of applicable licenses for the SRHCF administrator and medical director, if applicable;
   7. (7) The results of a criminal records check to include results for the state of New Hampshire for the applicant(s), licensee if different than the applicant, the administrator, the medical director, if applicable, and each household member 17 years of age or older who resides at the facility, as applicable;
   8. (8) A copy of the non-conviction attestation, as described in He-P 805.18(t), for the administrator and medical director;
   9. (9) The results of a bureau of adult and aging services (BAAS) registry check from the bureau of adult and aging services for the administrator and medical director pursuant to He-P 805.18(e);

   10. (10) Written local approvals as follows:

       1. 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. 1. The health officer verifying that the applicant complies with all applicable local health requirements and drinking water and wastewater requirements;
          2. 2. The building official verifying that the applicant complies with all applicable state building codes and local building ordinances;
          3. 3. The zoning officer verifying that the applicant complies with all applicable local zoning ordinances; and
          4. 4. The fire chief verifying that the applicant complies with the state fire code and local ordinances for a health care facility; and
       2. b. For a building under construction, the written approvals required by a. above shall be submitted at the time of application based on the local official’s review of the building plans and again upon completion of the construction project;
   11. (11) If the SRHCF uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485, Env-Dw 702.02, Env-Dw 704.02, or if a public water supply is used, a copy of a water bill;
   12. (12) Any waiver requests, if applicable; and
   13. (13) A list of all employees who have been previously granted waivers for criminal background check results from the department.

2. (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;

Source. #2261, eff 1-17-83; ss by #3193, eff 1-28-86; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92 New. #5513, eff 11-25-92; ss by #5665, eff 7-14-93; ss by #6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99 New. #8746, eff 10-25-06; ss by #10813, eff 4-21-15; ss by #13333, eff 1-25-22; ss by #14358, eff 8-28-25, EXPIRES: 8-28-35