HomeMy WebLinkAboutCert of Local Fire Inspection license renewal Apr 2026(@,
lnstructions: Facilities and pro8rams are to provide a copy ofthis 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 Oepartment, 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 IN FORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspection:
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tr lnitial Licensure Licensure Renewal tr Facility/Program Renovations
! Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
/et/z cL/,This is to document that the above facility/program was inspected on:
and determined to be:(Date)
I 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 violations is attached):
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Signature of Loca Fire Department Official
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Rev. 06./25115
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Typed or Prlnted Name of Local Fire Department Official
DEPARTMENT OF PUBTIC HEATTH
DIVISION OT HEATTH CARE FACIL]TY
tIC€NSURE & CERTIFICATION
67 Forest Street
Marlborourh, MA 01752
CERTIFICATION OF
LOCAT FIRE INSPECTION
INSPECTION INFORMATION