HomeMy WebLinkAboutCert of Local Fire Inspection June 2025(.@/,
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEAI,TH CARE FACILITY
LICEI{SURE & CERTIFICATION
67 torest Street
Marlboro MA 01752
lnstructions: Facilities and programs are to provide a copy of this form to their local Fire Oepartment 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).
Facility/Program Name
Facirity/ProsramAd o** 5 i1 \) ,,1 )v t {a tw,8 I
FACITITY/PROGRAM INFORMATION
Reason for lnspection
,iF
lnitial Licensure/ Licensure Renewal Facility/Pro8ram Renovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
(0\l
tr--Ln compliance with local ordinances regardint fire prevention and safety.
-
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):
'Ul'rt//L1
L
/
Signature Flre nt
f^rr" /"vo
ciaoffi
(-*
Re\. 06125i l5
Fire.3
Typed or Printed Nam€ of Local Fire Department Official
M^n\1,,,,.. ('*) Fo),UrrU
CERTIFTCATION OF
LOCAI. FIRE INSPECTION
(r
I
tr
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be: