HomeMy WebLinkAboutCert of Local Fire Inspection Nov 2025002(@J,
DEPARTMENT OF PUBTIC HEATTH
DIVISION OF HEALTH CARE FACITITY
LICEI{SURE & CERTIFICATION
57 forest Stre€t
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 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).
FACITITY/PROGRAM INFORMATION
C* lb,'/,t," sFacility/ProBram Name
Facility/Protram Address tb 0Or11q 9+ Vo.*.ul^lt ?,,a. }.tN oeG-U
Reason for lns ton:
lnitialLicensure/LicensureRenewal tr Facility/programRenovations
Nursing Home or Rest Home Quarterly tnspection (105 CMR 1SO.O15(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
Yz tn 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):
Si8nature of Local Fire Depanment Official
t-t ,^_/
Rev. 06i25/t5
Firc.3
Typed or Printed Name of Local Fire Oepanment Official
Marlborough, MA 01752
CERTIFICATION OF
LOCAL FIRE INSPECTION
(Date)