HomeMy WebLinkAboutCertificate of Local Fire Inspection Oct 2025(@,
DEPARTMENT OF PUBTIC HEATTH
DtvrtloN oF HEAT.TH CARE FAC|UTY
UCENSURE & CERTIfICATIOI{
57 Forest Stre€t
Marl MAOt752
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 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).
FACI LITY/PROGRAM INFORMATION
Facility/P rog ra m Name
Facility/Protram Address
Reason for lnspection:
n i \ta e1( 11
)
C
n 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 dtlermined to be:
-1 tn compliance with local ordinances regarding fire prevention a
L
(Date)
nd safety.
LT Ol,,ta 733
-
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):
ure of Local ire Depa ment Officrals
Rev.06/25l15
Firc.3
Typed or Printed Name of Local Fire Department Official
CERTIFICATION OF
LOCAL FIRE INSPECTION