HomeMy WebLinkAboutCert of Local Fire Inspection Nov 2025:ir^li:::]"T, .Facitities and programs are to provide a copy of this formrequesting a fire inspection for litheinspe;ion;;#;;,;:rff t'"TiJ:?f :,.';::T,;:""1#i:rJticense. Nursing homes and ,"rt t or". ,rrir.i^i.i"T"'# iLn ,n"as required under 105 CMR 1SO.Ot5(D).
to their local Fire Depanment whenams must return this form completed, orent,.when applying for or renewing afacility proof of quarterly fire inspectaons
(s),OEPARTMENT OT PUBUC HEALTH
DIVISION OF HEATTH CARE FACITIW
UCENSURC & CERTIFICATION
67 Forest Street
Ma MA 0r752
CERTIFICATION OF
TOCAI FIRE INSPECTION
FACITITY/PROGRA M INFORMATION
A?E Ab.\ ,I''e:Facility/program Name
Facility/program Address
Reason for lnspection:
M0ur-\S. rlar lv\A 026
'g/ ,n0,., ,,..nsury ticensure Renewal Facility/program Renovations
Nursing Home or Rest Home euarterly tnspection (10S CMR 150.015(D))
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INSPECTION INFO RMATION
This is to document that the abotand determined to be: ve facility/program was inspected on:I L-l (-\
Signature of Loca lFire Depanment Off;cial
r./ (Date){ tn compliance with local ordinances regarding fire prevention and safety.
_ Not to be in compliance w
,iorations weie iiJi#illffi L[Tffi;:il';i:,ffJi,:i;;;rli5:'.;,:;,le fo,,owing
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Rer'. 06125715
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lyped or pinted Name of Local Fire Department Official
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