HomeMy WebLinkAboutCert of Local Fire Inspection Nov 2025DEPARTMENT OF PUBTIC HEALTH
DIVISION OF HEATTH CARE FACIUTY
TICENSURE & CERTIFICATIOT{
67 Forest Street
Ma MA 01752
lnstructions: Facilities and proBrams 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 maintain on file with the facility proof of quarterly fire inspections
as required under 105 CMR 150.015(D).
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FACITITY/PROGRAM INFORMATION
Facility/ProBram Name
Facility/Program Address
Reason for lnspection:
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lnitial Licensure/ Licensure Renewal Facility/Program Renovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
LOZ5This is to document that the above facility/program was inspected on:
and determined to be:(oate)
\.,/-'/ ln compliance with local ordinances regarding fire prevention and safety.
_ Not to be in compliance with localordinances regarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
Sitnature of Local Fire Depanment Official
LT O/tr'x
Rev.06125/15
Firc.3
Typed or Printed Name of Local Fire 0epartment Official
(@ CERTIFICATION OF
LOCAL FtRE INSPECTION
INSPECTION INFORMATION