HomeMy WebLinkAboutCert of Local Fire Inspection Jun 2026i-i-
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DEPARTMENT OF PUBLIC HEALTH
DIVISIOTT OF HEAITH CARE FACIL]rY
TICEI{sURE & CERTIFICATION
67 Forest Street
Ma MA 07752
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. 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).
FACILIryPROGRAM INFORMATION
Reason for ln
a{oo,tVt tt^'7
n
lnitial Licensure/ Licensure Renewal Facility/Program Renovations
n Nursing Home or Rest Home Quarterly tnspection (105 CMR 15O.O1S(D))
This is to document that the above facility/program was inspected on:
and de ined to be:(Oate)
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):
Signature of Local Fire Department Official
L+. Cli"* )s
Rev. 06/25/15
Firc.3
Typed or Printed Name of Local Fire Depa(ment Official
CERTIFICATION OF
LOCAT FIRE INSPECT]ON
Shtrt r\/hI- dl-t?(;-Facility/Program Name
Facility/Program Address
INSPECTION INFORMATION