HomeMy WebLinkAboutcertificate of local fire inspection October 2025DEPARTMENT OF PUBLIC HEATTH
DIVISION OT HEAITH CARE FACILITY
TICENSURE & CERTIFICATION
57 Forest Street
CERTIFICATION OF
TOCAL FIRE INSPECTION
FACILITY/PROGRAM INFORMATION
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Facility/Program Address
Reason for lnspection:
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NursinS Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))A
This isto document that the above facility/program was inspected on: /o- g- 2S-
and determined to be: (Date)
^ ln compliance 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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siBnature of Local Fire Depadment Official
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Typed or Printed Name of Local Fire Department Official
(@:
Marlborough, 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 thls form completed, or
the inspection certificate issued by the head of their local Fire Oepartment, 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).
INSPECTION INFORMATION
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Rev. 06/25115
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