HomeMy WebLinkAboutCert of Local Fire Inspection Nov 2025.@,
DEPARTMENT OF PUBTIC HEALTH
DIVISION Of HEALTH CARE FACIUTY
LICENSURE & CERTIFICAIION
57 Forest Street
FACITITY/PROGRAM I NFORMATION
(ow Abrtrl*rFacility/Program Name
Facility/Program Address
Reason for lnspection:
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lnitialLicensure/LicensureRenewal tr Facility/programRenovations
Nursing Home or Rest Home Quarterly tnspection (105 CMR 15O.O15(D))
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and d2
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termined to be:
ln compliance with localordinances regarding fire prevention and safety
(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):
SiSnature of Local fire Depanment Official
,J-6I'tr-
Rev. 06.125115
Fire.3
Typed or Printed Name ot Local Fire Department Ofticial
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, orthe inspection certificate issued by the head of their local Fire Department, when applying for or renewing alicense. Nursing homes and rest homes must maintain on file with the facality proof of quirterly fire inspections
as required under 105 CMR 150.015(D).
Marlborough, MA 01752
CERTIFICATION OF
LOCAL FIRE INSPECTION
tr
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
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