Section He-P 827.04 - License Application Submission(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" (March 2019) 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 FMRTF 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 FMRTF 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 FMRTF;(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; orc. "Certificate of Trade Name," where applicable;(4) A $500 fee, in accordance with RSA 151:2-e, 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 FMRTF administrator;(6) Copies of applicable licenses for the FMRTF 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, as amended pursuant to RSA 153:5, I, by the state fire marshal with the board of fire control, as adopted by the commissioner of the department of safety, and local fire ordinances applicable for a business; 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 FMRTF 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(s), licensee if different than the applicant, medical director, and administrator for which the application is submitted; and(10) A copy of the signed and dated FMRTF's criminal statement form for the administrator and medical director as described in He-P 827.18(t) .(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
(c) A previously operating special health care service shall not be required to apply for a licensed pursuant to RSA 151:2-e.N.H. Admin. Code § He-P 827.04
Adopted by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12751, Effective 3/26/2019, Expires 3/26/2029.