HomeMy WebLinkAboutcert of local fire inspection apr 2024(@:
DEPARTMENT OF PUBLIC HEALTH
DIVISION OT HEALTH CARE FACITITY
tIC€ SURE & CERTIFICATION
67 Forest Street
Marlborouth. MA 01752
CERTIFICATION OF
LOCAT 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 certificate issued by the head oftheir local Fire Department, 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).
FACI LITY/PROGRAM I NFORMATION
Facility/Program Name /L 4 {/tqer ./Uurrc".t1,.
Facility/ProgramAddress I )7 l<Zn/e',;/<o
Reason for lnspection: ,,, I
8I tnitial Licensure/ Licensure Renewal tr Facility/Program Renovations
Nursin8 Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:
q'//'21/
(Date)
_ Not to be in compliance with localordinances regarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
la d-/)
,^sg;;;r Lo.at@ oe p" n."ni6f;ici" t
LkL)7*,r<
Rev.06/25/15
Fire.3
Typed or Printed Name of Local Fire oepartment Offacial
INSPECTION INFORMATION
X tn compliance with local ordinances regarding fire prevention and safety.
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