He-P 805.04 Initial License Application Submission.

  • Each applicant for a license shall comply with the requirements of RSA 151:4, I–III-a and submit the following to the department:
    • 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.”;

  • A floor plan of the prospective SRHCF;
  • 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:
    1. “Certificate of Authority,” if a corporation;
    2. “Certificate of Formation,” if a limited liability corporation; or
    3. “Certificate of Trade Name,” where applicable;
  • 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”;
  • A resume identifying the qualifications of the SRHCF administrator;
  • Copies of applicable licenses for the SRHCF administrator;
  • Written local approvals as follows:
    1. 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


  1. 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
  • 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 01.
  • The applicant shall mail or hand-deliver the documents to: Department of Health and Human Services
  • The applicant shall have on hand and available for inspection at the time of the initial onsite inspection the following:
    • The results of a criminal records check from the NH department of safety for the administrator and each household member, as applicable;
    • A copy of the SRHCF’s admission agreement; and
    • A copy of the SRHCF’s standard disclosure