HomeMy WebLinkAboutCert of Local Fire Inspection Apr 2024DEPARTMENT OF PUBTIC HEALTH
DIVISION OF HEALTH CARE FACILITY
TICENSURE & CERTIFICATION
57 Forest Street
Marl MA 017S2
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 of their 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
5k, t/n t1./,,'.u1Facility/Program Name
Facility/Program Address
Reason for lnspection:
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E lnitial Licensure/ Licensure Renewal ! Facility/Program Renovations
n Nursing Home or Rest Home Quarterly Inspection (105 CMR 150.015(D))
This is to document that the above facility/program was inspected on:
and determined to be:
q) y' )'/
(Date)
Y 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 Fire 0epanment Official
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Rev. 06/25115
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Typed or Printed Name of Local Fire Department Official
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INSPECTION INFORMATION
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