HomeMy WebLinkAboutCert of Local Fire Inspection Jan 2026(@,
DEPARTMENT OF PUELIC HEALTH
DIVISION OF HEALTH CARE FACIL.]TY
TICENSURE & CERTIFICATION
67 torest Street
Marlboro MA 01752
CERTIFICATION OF
LOCAL FIRE INSPECTION
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, 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).
FACITITY/PROGRAM I NFORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspection:
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lnitialLicensure/LicensureRenewal n Facility/ProgramRenovations
tr Nursing Home or Rest Home Quarterly Inspection (105 cMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:
X 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 vlolations is attached):
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Depanment Official
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Typed or Printed Name of Local Fire Depanment Official
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INSPECTION INFORMATION '-8 ) c
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Signature of Local
Rev. 06i25/15
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