HomeMy WebLinkAboutCert of Local Fire Inspection May 2024DEPARTMET{T OF PUBLIC HEALTH
OIVISION OF HEALTH CARE FACITITY
UCENSURE & CERTIFICATION
67 Forest Street
Ma MA 017s2
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 Department, when applying for or renewing a
license. NursinB homes and rest homes must maintain on file with the facility proof of quarterly flre inspections
as required under 105 CMR 150.015(D).
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FACILITY/PROGRAM INFORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspection:
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lnitial Licensure/ Licensure Renewal tr Facility/Program Renovations
Nursing Home or Rest Home Quarterly hspection (105 CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:
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(Date)x ln compliance with localordinances regarding fire prevention and safety.
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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):
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Signature of Local Fi Depanment Official
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Rev. 06/25115
Fire,3
Typed or Printed Name of Local Fire Department Official
(@,CERTIFICATION OF
LOCAL FIRE INSPECTION
INSPECTION INFORMATION
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