HomeMy WebLinkAboutcert of local fire inspection June 2024(@),CERTIFICATION OF
TOCAL FIRE INSPECTION
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 Department, when applying for or renewing a
license. Nursang 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 INFORMATION
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Nursing Home or Rest Home Quanerly lnspection (105 CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:
X ln compliance with local ordinances reSarding 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 L Fire 0epartment Official
/l 1r 7 r,not:,
DEPARTMENT OF PUBTIC HEATTH
DIVISION Of HEATTH CARE FACILITY
TICENSURE & CERfITICATION
67 Forest Street
Marlborourh, MA 01752
Facility/Program Name
Facility/Program Address
Reason for lnspection:
INSPECTION INFORMATION
Ju^re 2I . 2o: Y
(Date)
Rev.06/25/15
Firc.l
Typed or Printed Name of Local Fire Depanment Official