HomeMy WebLinkAboutcert of local fire inspection May 2026(@,
DEPARTMENT OF PUBLIC HEATTH
DIVISION OF HEATTH CARE FACILITY
LICENSURE & CERTIFICATION
67 torest Street
Marlbo 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 cenificate issued by the head of their local Fire Department, when applying for or renewint 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).
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FACI LITY/PROGRAM INFORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspe n:
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lnitialLicensure/LicensureRenewal ! Facility/ProgramRenovations
Nursin8 Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
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and yrmined to be:
X ln compliance with local ordinances reEarding fire prevention and safety
(Date)
-
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):
lFire ial
This is to document that the above facility/program was inspected on:
Rev. 0645/15
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nJgr{e of Local Fire Depanment Ofticial
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INSPECTION INFORMATION
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