HomeMy WebLinkAboutCert of Local Fire Inspection Feb 2026@J,
DEPARTMENT OF PUBLIC HEALTH
DIVISIOI{ OF HEATTH CARE FACITITY
TICENSURE & CERTIFICATION
67 Forest Street
Marl MA 01752
CERTIFICATION OF
LOCAT 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).
Facility/Program Name Shie\!'= I\\GL a4 Cqre CaJ
FACII.ITY/PROGRAM INFORMATION
I qv\nOt^KD "<+b.(iwotx l^ A 626-i-Vr.-r ?Facility/Program Address
Reason for lnspection:
fi( ,nn,., Licensure/ Licensure Renewal tr Facility/Protram Renovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
)lolz,za
(Date)
-)3SiSnature of Local Fire Depanment Ofticial
L+. Olir,r^,
Rcv.06/25/15
Fire.3
Typed or Printed Name oI t-ocal Fire Department Official
2J
tr
Y n comptiance with local ordinances regardinS 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):