Current through Register No. 40, October 3, 2024
(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) A completed application
form entitled "Application for Residential or Health Care License" (3/11/2013)
, signed by the applicant or 2 of the corporate officers, 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) A floor plan of
the prospective SRHCF;
(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:
a. "Certificate of Authority," if a
corporation;
b. "Certificate of
Formation," if a limited liability corporation; or
c. "Certificate of Trade Name," where
applicable;
(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) A resume identifying the qualifications
of the SRHCF administrator;
(6)
Copies of applicable licenses for the SRHCF 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; and
4. The fire chief
verifying that the applicant complies with the state fire code, including the
health care chapter of NFPA 101 as adopted by the department of safety, and
local fire ordinances applicable for a health care facility; and
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
(8) If the SRHCF uses a private
water supply, documentation that the water supply has been tested in accordance
with RSA 485 and Env-Ws 313.01 and Env-Ws 314.01.
(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
(c) The applicant shall have on hand and
available for inspection at the time of the initial onsite inspection the
following:
(1) The results of a criminal
records check from the NH department of safety for the administrator and each
household member, as applicable;
(2) A copy of the SRHCF's admission
agreement; and
(3) A copy of the
SRHCF's standard disclosure form.
#2261, eff 1-17-83; ss by #3193, eff 1-28-86; ss by
#5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92
