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” (February 2023), signed by the applicant or 2 of the corporate officers affirming 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) 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 company; or
      3. c. “Certificate of Trade Name,” where applicable;
   3. (3) The applicable fee, in accordance with RSA 151:5, XXII 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”;
   4. (4) A resume identifying the qualifications of the CMA administrator;
   5. (5) Copies of applicable licenses for the CMA 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 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 fire ordinances; 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; and
   7. (7) For the applicant(s), licensee, and administrator, the results of a criminal records check. Results shall include criminal history from the state of New Hampshire.

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

   Department of Health and Human Services

   Bureau of Licensing and Certification

   Health Facilities Administration

   129 Pleasant Street

   Concord, NH 03301

Source. #10260, eff 1-25-13; ss by #13709, eff 8-1-23