Current through Register No. 40, October 3, 2024
(a)
Each applicant for a license shall comply with the requirements of RSA
151:4II(a), I-I, and submit the following to the department:
(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:
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.";
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
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) A floor plan of the prospective
RTRF;
(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:
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,
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) A resume
identifying the name, qualifications, and copies of applicable licenses for the
RTRF administrator;
(6) 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;
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, 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
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) 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) 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.
(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
