HomeMy WebLinkAboutCert of Local Fire Inspection 2025DEPARTIvtENT OF PUBtIC HEALTH
DIVISION OF HEALTH CARE FACITITY
TICENSURE & CERTIFICATION
57 Forest Street
MA MA 01752
lnstructions: Facilities and proBrams 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 renewing 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).
FACITITY/PROGRAM INFORMATION
Y trEnA />q aFacility/Program Name
Facility/Program Address
Reason for lnspection:
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tr lnitial Licensure/ Licensure Renewal Facility/Pro8ram Renovations
R Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:(Date)
_ 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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SiSnature of Local Fire Depanme rcra
1 lrL 0
Rev. 0625/15
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Typed or Printed Name of Local Fire Depanment Official
(@,CERTIFICATION OF
TOCAL FIRE INSPECTION
INSPECTION INFORMATION
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tl\ ln compliance with localordinances reBardin8 fire prevention and safety.