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" (May 2017 edition), signed
by the applicant or 2 of the corporate officers, affirming and certifying 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 a license, or
imposition of a fine.";
b. For any
ADP to be newly licensed on or after July 1, 2016:
"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 ADP to be newly licensed on or after July 1, 2016 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
ADP;
(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, XX, payable in cash
in the exact amount of the fee 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 and qualifications of the ADP administrator;
(6) Copies of applicable licenses,
certificates, or both, for the ADP 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, Saf-C 6000,
including the day-care occupancies chapter of National Fire Protection
Association (NFPA) 101, as adopted by the commissioner of the department of
safety under RSA 153, and as amended pursuant to
RSA
153:5, I, by the state fire
marshal with the board of fire control, 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 the
application based on the local official's review of the building plans and
again upon completion of the construction project;
(8) If the ADP uses a private water supply,
documentation that the water supply has been tested in accordance with RSA 485
and and Env-Dw 702.02 and
Env-Dw
704.02, or if a public water supply, a copy of a water
bill; and
(9) The results of a
criminal records check from the NH department of safety for the applicant(s),
licensee if different than the applicant, administrator, and household
members.
(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
