HomeMy WebLinkAboutcert of local fire inspection may 2024DEPARTMENT OF PUBTIC HEATTX
DIVISION OF HEATTH CARE FACIUTY
LICENSURE & CERTIFICATION
57 For$t Street
Marlboro , MA 01752
lnstructions: Facilities and programs 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).
FACILITY/PROGRAM INFORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspection:
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This is to document that the above facility/program was inspected on:
and determined to be:
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(Date)
X tn 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 f ire 0epanment Otficial
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Rev. 06/25115
Fire.3
Typed or Printed Name of l-ocal Fire Depanment Official
CERTIFICATION OF
LOCAT FIRE lNSPECTION
E lnitial LicensurV Licensure Renewal tr Facility/Protram Renovations
tr Nursing Home or Rest Home quarterly lnspection (1OS CMR 150.015(D))
INSPECTION INFORMATION