HomeMy WebLinkAboutcert of local fire inspection Jan 2025@,
DEPARTMENT OF PUBTIC HEALTH
DIVISIOT{ OF HEATTH CARE FACILITY
TICENSURE & CIRTIFICATION
67 forest Street
Marlborough, MA 01752
CERTIFICAT!ON OF
TOCAL FIRE INSPECTION
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 renewing a
license. Nursing homes and rest homes must maantain on file with the facility proof of quarterly fire inspections
as required under 105 CMR 150.015(D).
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FACI LITY/PROGRAM INFORMATION
Facility/Pro8ram Name
Facility/Program Address
Reason for lnspection:
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lnitial Licensure/ Licensure Renewal Facility/Program Renovations
E-Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
INSPECTION INFORMATION
This is to document that the above facality/program was inspected on:
and determined to be:
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(Date)
)' tn compliance with local ordinances regarding fire prevention and safety
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Not to be in compliance with local ordinances regardint fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
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Signature of Local Fire Depanment Official
Typ€d or Printed Name of Local Fire Depanment Official
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Rev. 06i25/15
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