(1) A completed application form entitled
"Application for Residential or Health Care License," (September 2018 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 the
license and the imposition of a fine."
b. For any SUD-RTF 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 SUD-RTF 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
SUD-RTF;
(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,
XXI, 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 SUD-RTF administrator and medical
director;
(6) Copies of applicable
licenses for the SUD-RTF administrator and medical director;
(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, 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, 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 including, at a minimum, the new
residential board and care chapter of the life safety code, and the applicable
local fire ordinances; 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 upon
completion of the construction project;
(8) If the SUD-RTF 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 a public water supply, a copy of a water
bill;
(9) The results of a criminal
records check from the NH department of safety for the applicant, licensee if
different from the applicant, administrator and medical director for which the
application is submitted;
(10) A
copy of the SUD-RTF's admission agreement;
(11) A copy of the SUD-RTF's criminal
attestation form as described in He-P 826.18(u);
(12) A complete description of all services
provided or to be provided including a determination of which of the following
tier(s) the facility falls into:
a. Tier 1-
Full Medical Withdrawal Management;
b. Tier 2- Limited Medical Withdrawal
Management; or
c. Tier 3-
Residential Treatment; and
(13) Documentation, required by
RSA 151:4, III(a) (5)
, that the public has been notified of the
intent to open a licensed facility by notice published in a newspaper, covering
the area in which the licensed facility or service is to be operated, in at
least 2 editions of the paper within 10 days of the filing of the application
for a license. Such notice shall include a description of the facility and
services to be offered.
