HomeMy WebLinkAboutcert of local fire inspection May 2026@,
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH CARE FACIL]fl
LICE SURE & CERTIFICATIOT{
67 For€st Street
Marlborough, MA 01752
lnstructions: Facilities and pro8rams 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 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).
ls 8\tnrnc (trk( LUesJ 6f 1n6 t,tkueFacility/Program Name
Facility/Program Address
Reason for lnspection:
\3O A''.:e\ Ha\aY \-rC ,t-OOt \ar,ruro.rtr,r ,o-rG-73
lnitial Licensure/ Licensure Renewal
tr Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
FACILIW/PROGRAM INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
5 ,))olb
(Date)
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):
Signature of Local Fire Depanment Of{icial
Lr 0l',"
Re!.06i25/15
Fire.3
Typed or Printed Name of Local Fire Depanment Official
CERTIFICATION OF
LOCAL FIRE INSPECTION
tr Facility/Program Renovatio ns
INSPECTION INFORMATION