N.H. Admin. Code § He-C 4001.02 - Application Form and Attachments

(a) All applicants for licensure shall complete and submit an application form to the department, which includes:

(1) Whether the application is for a new, renewed, or revised license;

(2) Whether the program will operate a group home, child care institution, independent living home, homeless youth shelter, or specialized care program;

(3) Whether the applicant, owner, or business organization intends to provide short-term placements;

(4) The name, physical address, mailing address, and telephone number of the program;

(5) The name, telephone number, and mailing address of the applicant, owner, or business organization;

(6) An e-mail address for the program and the applicant, owner, or business organization, if available;

(7) Federal tax identification number if one has been assigned;

(8) A list of all buildings in which residents will be cared for which identifies:

a. The building identifier;

b. The building's purpose or function;

c. The type(s) of residential child care services that the applicant, owner or business organization intends to offer in the building as specified in He-C 4001.02(a)(2) above; and

d. The proposed number of residents and age range to be cared for in each residential building;

(9) The total requested resident capacity of the program;

(10) How the program is owned and organized, whether private, partnership, or other organization type, including name of business organization, business identification number, and the names, title/position, and telephone numbers of the officers of the business or board members, if applicable;

(11) Whether the program will be operating as for-profit or non-profit;

(12) The name, birth name(s), and date of birth of the program director;

(13) The qualifications of the program director, including education and experience;

(14) For persons who have contact with residents in the residential child care program, more than 5 hours per week, excluding residents who are admitted to the program, and including any applicant, owner, officer of the business organization, program director, executive director, board member, household member, program staff, intern, volunteer or any other individual in the state of New Hampshire or the United States, information and details disclosed by the individual on their application for employment, or otherwise known by the program, regarding the following:

a. Criminal convictions in a state other than New Hampshire;

b. Current criminal investigations in any state;

c. Current investigations of child abuse or neglect in any state;

d. Previous findings of child abuse or neglect in a state other than New Hampshire;

e. Current investigation of juvenile delinquency for juvenile household members; and

f. Previous adjudications of juvenile delinquency for juvenile household members;

(15) The information required by (14) above shall include:

a. The name and position or affiliation of the individual;

b. Whether this information is a charge, allegation, conviction, finding, or current investigation;

c. The name and city of the court of DCFY office in which the case was handled, as applicable; and

d. The date of any conviction or finding;

(16) A statement dated and signed by the program director and the applicant, or an individual legally authorized to sign for the applicant attesting to the following:

"I HAVE READ AND AM IN COMPLIANCE WITH ALL APPLICABLE RULES IN He-C 4001";

"I UNDERSTAND THAT THE DEPARTMENT MAY INVESTIGATE ANY CRIMINAL CONVICTION RECORD, FINDING OF CHILD ABUSE OR NEGLECT, OR INVESTIGATION OF OR FINAL DETERMINATION REGARDING ANY JUVENILE DELINQUENCY AND WILL MAKE A DETERMINATION REGARDING WHETHER THE INDIVIDUAL POSES A CURRENT RISK TO THE HEALTH, SAFETY OR WELL BEING OF CHILDREN";

"I UNDERSTAND THAT THE DEPARTMENT MAY DELAY ITS DECISION TO APPROVE OR DENY THIS APPLICATION PENDING THE OUTCOME OF ANY INVESTIGATION, WHEN THE APPLICANT, OWNER, OR PROGRAM DIRECTOR, ARE NAMED AS THE PERPETRATOR IN ANY CURRENT INVESTIGATION OF ANY CRIME, OR IN AN ALLEGATION OF ABUSE OR NEGLECT";

"I UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS APPLICATION OR ANY OF THE ATTACHMENTS, OR FAILING TO DISCLOSE ANY INFORMATION REQUIRED ON THE APPLICATION, OR REQUIRED TO BE SUBMITTED WITH THIS APPLICATION, SHALL BE CONSIDERED GROUNDS FOR LICENSE DENIAL OR REVOCATION";

"I HAVE READ THE NH RESIDENTIAL CHILD CARE PROGRAM LICENSING RULES, AND UNDERSTAND THAT FAILURE TO MAINTAIN MY PROGRAM IN COMPLIANCE WITH THE APPLICABLE RULES, MAY JEOPARDIZE MY LICENSE/PERMIT";

"I AUTHORIZE ANY POLICE DEPARTMENT, COURT SYSTEM OR HUMAN SERVICE AGENCY IN THIS OR ANY OTHER STATE TO RELEASE COPIES OF ANY CRIMINAL RECORDS OR CHILD ABUSE OR NEGLECT RECORDS TO THE DEPARTMENT"; and

"ALL INFORMATION PROVIDED AS PART OF THIS APPLICATION AND IN THE REQUIRED ATTACHMENTS IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE";

(17) The position of the individual who signed pursuant to (16) above, such as applicant, board president, board secretary, executive director, or program director;

(18) For each building, a floor plan diagram of indoor residential childcare space which shall specify:

a. Room dimensions;

b. Location of exits;

c. How each room will be used;

d. The location of bathrooms and bathroom fixtures, including toilets, sinks, bathtubs, and showers;

e. The location of other hand-washing sinks; and

f. The length, width, and ceiling height of each bedroom;

(19) For each building, a diagram of outdoor play and recreation space which shall specify:

a. The overall dimensions of the outdoor play space including the length and width of the space;

b. The locations of exits, gates, and stationary outdoor play or recreation equipment, including the location of and type of fencing, if any, including gates;

c. The location of the outdoor play space in relation to the indoor space; and

d. The location and description of any outdoor water and street hazards including the presence of and location of any pools, ponds, streams, rivers, streets, roads, or other hazards that are in close proximity;

(20) For renewal or revisions applications, diagrams as specified in (18) and (19) above if changes have been made in the residential child care space since the last application submitted to the department; and

(21) For renewal or revision applications, a check mark in the box on the form, indicating when no changes have been made to residential child care space since the last application submitted to the department.

(b) Residential child care programs that have multiple buildings on the same or adjoining property may apply for a single license for those multiple buildings provided that:

(1) In accordance with residential child care space requirements specified in He-C 4001.16, each residence has adequate square footage, common living space, and complete bathroom units for the number of residents who will reside in each building;

(2) An individual who meets at least the minimum qualifications of a direct care staff is designated in charge in each building; and

(3) All program staff and residents are aware of the identity of the direct care staff who is designated in charge in each building.

(c) With the application, the applicant shall submit to the department a completed "Health Officer Inspection Report for Residential Child Care Agencies" form (10/2014 edition) completed by the local health officer or duly appointed designee, for each building inspected, documenting that within the 12 months of the date the department receives the application, the premises have been inspected and approved by a local health officer or duly appointed designee for operation as a residential child care program.

(d) With the application, the applicant shall submit to the department a completed "NH State Fire Code compliance report" documenting that, within the 12 months of the date the department receives the application, the premises have been inspected by the local fire department or the state fire marshal's office, for compliance with the applicable parts and sections of the State Fire Code, under RSA 153:1, VI-a, and Saf-FMO 300, including but not limited to NFPA 1 and NFPA 101, and as amended by the state board of fire control and ratified by the general court pursuant to RSA 153:5, and approved to operate as a residential child care program.

(e) The "NH State Fire Code compliance report" required under (d) above shall include the following:

(1) Completed by either program personnel or the fire inspector:

a. The name, address, telephone number, and license number of the residential child care program;

b. The name of the applicant;

c. The type of residential child care to be provided; and

d. The number and age range of residents for whom the applicant intends to provide care; and

(2) Completed by the fire inspector:

a. The date the premises were inspected by the fire inspector;

b. For each building which will be used by residents:

1. An indication regarding whether the fire inspector approves or does not approve the premises to operate as a residential child care program;

2. Any areas of non-compliance with the State Fire Code, under RSA 153:1, VI-a, Saf-C 6000, and Saf-FMO 300, including but not limited to NFPA 1 and NFPA 101, and as amended by the state board of fire control and ratified by the general court pursuant to RSA 153:5; and

3. Any conditions or restrictions placed by the fire inspector, including but not limited to, any limits relative to the number and age range of residents to be cared for in the program or any rooms, levels, or other areas of the premises not approved for use by residents;

c. An indication whether or not the fire inspector approves, does not approve, or grants a conditional approval for the residential agency type(s) to operate.

d. If a conditional approval is granted, it shall include:

1. The details regarding what action must be taken; and

2. The date the conditional approval will expire;

e. The printed name, address, telephone number, and title of the fire inspector;

f. The dated signature of the fire inspector; and

g. The city or town in which the fire inspector has authority.

(f) With the application, the applicant shall submit to the department documentation from the applicable town or city that the program has been granted zoning approval or a statement that no zoning approval is required.

(g) The zoning documentation required in (f) above shall include the following:

(1) The name and address of the program;

(2) The name of the applicant;

(3) Any zoning requirements or restrictions imposed by the town or city regarding the existence of the program, including any limits regarding ages or number of residents to be cared for in the program, and any buildings on the property that do not have zoning approval; and

(4) The signature of an individual authorized to sign on behalf of zoning, and date signed.

(h) With the application, the applicant shall submit to the department background check forms as specified in He-C 4001.31 for each of the following:

(1) The applicant;

(2) All household members; and

(3) All program directors.

(i) With the application, the applicant shall submit to the department documentation of education and experience that shows that the program director meets the requirements for his or her position, as specified in He-C 4001.19(e).

(j) The documentation of education and experience required under (i) above shall include the following:

(1) Copies of transcripts, certificates, diplomas, or degrees as applicable; and

(2) A resume or other documentation of previous experience.

(k) With the application, applicants that are incorporated shall submit to the department a list of the names, addresses, and telephone numbers of the current board members.

Notes

N.H. Admin. Code § He-C 4001.02

#2664, eff 3-30-84, EXPIRED: 3-30-90

New. #8581, eff 4-20-06, EXPIRED: 4-20-06

New. #10576, INTERIM, eff 4-26-14, EXPIRES: 10-23-14

Amended byVolume XXXIV Number 46, Filed November 13, 2014, Proposed by #10705, Effective 10/23/2014, Expires10/23/2024. Amended by Volume XLI Number 06, Filed February 11, 2021, Proposed by #13151, Effective 12/30/2020, Expires 12/30/2020.