HomeMy WebLinkAboutcert of local fire inspection Apr 2026(@,
DEPARTMENT OF PUBTIC HEATTH
DIVISION OT HEALTH CARE FACIL]TY
UCET{5URE & CERTIFICATION
57 forest Street
Marlborough, MA 01752
CERTIFICATION OF
LOCAL FIRE !NSPECTION
lnstructions: Facilities and proBrams 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 thls form completed, or
the inspection certificate issued by the head of their local Fire Department, when applying for or renewing a
license. Nursin8 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 INFORMATION
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lnitial Licensure/ Licensure Renewal
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
Fa c ility/ P rog ra m Renovations
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
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(Date)
ln compliance with local ordinances regarding fire prevention and safety.
_ Not to be in compliance with local ordinances retarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
5iSnature of Local re Department ial
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Rev. 0625/15
Fire.l
Typed or Printed Name of Local Fire Department Official
Facility/Program Name
Facility/Program Address
Reason for Inspection:
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