HomeMy WebLinkAbout782 Rte 28 local fire insp 2025001.@
DEPARTMENT OF PUBTIC HEALTH
DIVISION OF HEAI.TH CARE FACILITY
TICE SURE & CERTIFICATION
67 Forest Street
Ma MA 01752
lnstructions: Facilities and programs are to provide a copy of this form to their local Fire Department when
requesting a fire inspection for licensure purposes. Facilities and programs must return this form completed, or
the inspection certificate issued by the head of their local Fire Department, when applying for or renewint a
license. Nursing homes and rest homes must maintain on file with the facility proof of quarterly fire inspections
as required under 105 CMR 150.015(D).
FACI LITY/PROGRAM INFORMATION
)/Facility/Program Name
Facility/Program Address
Reason for lnspection:
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^K lnitial Licensure/ Licensure Renewal Facility/Program Renovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
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X tn.ornptiance with local ordinances regarding fire prevention and safety.
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Not to be in compliance with local ordinances regarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
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Si8nature of Local Fire Department Officaat
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Rcv.06./25/15
Fire.3
Typed or Printed Name of Local Fire Depanment Official
CERT!FICAT]ON OF
TOCAL FIRE INSPECTION
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