HomeMy WebLinkAboutcert of local fire inspection May 2026001(@},
OEPARTMENT Of PUBLIC HEALTH
OIVISION OF HEAI.TH CARE FACILITY
LICENSURE & CERTIFICATION
67 Forest Street
Marl 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
requestinS 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).
FACITITY/PROGRAM INFORMATION
)oTtl J h o,rl t"Facility/Program Name
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Reason for lnspection:
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Nursing 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:(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):
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Signature of Local ti Depanment Official
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Rev. 06/25l15
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Typed or Printed Name of Local Fire Depanment Official
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INSPECTION INFORMATION
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