HomeMy WebLinkAboutCert of Local Fire Inspection Nov 2025lnstructions: 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 facility proof of quarterly fire inspections
as required under 105 CMR 150.015(D).
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DEPARTMENT OF PUBLIC HEAITH
DIVISION OF HEALTH CARE
'ACILITYUCENSURE & CERTIFICATION
67 Forest Street
Ma MA 01752
FACI LITY/PROGRAM INFORMATION
Facility/Program Name
Facility/Program Address oc&*. Lt)irurr.r\ Jot \- I\A A Aot<
Reason for lns ction:
lnitial Licensure/ Licensure Renewal Facility/Program Renovations
n Nursing Home or Rest Home Quarterly tnspection (10S CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and rmined to be:(Date)
ln compliance with local ordinances regarding fire prevention and safety.
-
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):
Signature of Local Fire Department Official
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Typed or Printed Name of Local Fire Department Official
CERTIFICATION OF
TOCAL FIRE INSPECTION
INSPECTION INFORMATION
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