Assisted Living Licensure Application Addendum:
This is an addendum to the assisted living licensing application form. Use this document if
additional building identification information is needed for your application.
Applicants must upload attachments to the MDH application portal with their application.
No assisted living services shall be provided until MDH issues a license.
Keep a copy of application and attachment materials. They will not be returned to applicants.
Minn. Stat, sect. 144G.12, subd. 1(4) (https://www.revisor.mn.gov/statutes/cite/144G.12)
For each building, provide the requested information below.
1. Building Health Facility Identification (HFID) number, if the building was previously
assigned one: __________________________________________________________
2. Address: ______________________________________________________________
3. Building identification information (ex. Building A or Building B): __________________
4. City: __________________________________________________________________
5. State: ________________________________________________________________
6. ZIP: __________________________________________________________________
7. Building property identification number: _____________________________________
8. Building total licensed resident capacity for licensed period: _____________________
9. Number of floors in building not including basement: __________________________
10. Does the building have a basement?
11. Building size in square feet: _______________________________________________
12. Indicate type of construction per National Fire Protection Association 220, Standard
on Types of Building Construction (https://www.nfpa.org/):