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 License, or Special Health Care Services” (March 2019) signed by the applicant or 2 of the corporate officers affirming the following:

      1. a. “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. b. For any new RTRF to be newly licensed:

         “I certify that I have notified the public of the intent to file this application with a

         description of the facility to be licensed by publishing a notice in a newspaper of general circulation covering the area where the facility is to be located in at least 2 separate issues of the newspaper no less than 10 business days prior to the filing of this application.”; and

      3. c. For any RTRF to be newly licensed and to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. 485.610 (b) and (c):

         “I certify that the facility is to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. 485.610 (b) and (c), and that I have given written notice of the intent to file this application with a description of the facility to be licensed to the chief executive officer of the hospital by registered mail no less than 10 business days prior to the filing of this application.”

   2. (2) A floor plan of the prospective RTRF;

   3. (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:

      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, 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. (5) A resume identifying the name, qualifications, and copies of applicable licenses for the RTRF administrator;

   6. (6) 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;
         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, Saf-C 6000 under RSA 153 and as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control, including the applicable chapter National Fire Protection Association (NFPA) 101 , and local fire ordinances applicable for an RTRF; and
      2. b. For a building under construction, the written approvals required by a. above shall be submitted at the end of construction based on the local official’s review of the building plans and their final on-site inspection of the construction project;
   7. (7) If the RTRF uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02 and Env-Dw 704.02, or if public water supply, a copy of a water bill; and
   8. (8) The results of a criminal records check from the NH department of safety for the applicant(s), licensee if different from the applicant and the administrator for which the application is submitted.

2. (b) The applicant shall mail or hand-deliver the documents to:

   Department of Health and Human Services

   Health Facilities Administration

   129 Pleasant Street

   Concord, NH 03301

Source. #9873-B, eff 2-24-11; ss by #12727, INTERIM, eff 2-20-19, EXPIRED: 8-19-19 New. #12962, eff 12-31-19