HomeMy WebLinkAboutcert of local fire inspection may 2024(@:
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 renewint a
license. Nursint 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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FACILIw/PROGRAM INFORMATION
Facility/Protram Name
Facility/Program Address
Reason for lnspection:
to).oun(
E lnitial Licensure/ Licensure Renewal tr Facility/Program Renovations
tr Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
702
(Date)
ln compliance with local ordinances regarding fire prevention and safety
_ Not to be in compliance with localordinances retarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
SiSnature of Loca Fire Department Oflicial
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Rcv.06/25115
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Typed or Printed Name of Localtire Department Official
DEPARTMENT OF PUBTIC HEATTH
DIVISION OF HEATTH CARE FACILITY
TICEi,ISURE & CERTIFICATION
67 Forest Streel
Marlborourh, MA O1752
CERTIFICATION OF
LOCAL FIRE INSPECTION
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
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