HomeMy WebLinkAboutcert of local fire inspection Jul 2024(@),
OEPARTMENT OF PUBTIC HEATTH
DIVISION OF HEATTH CARE FACILTTY
TICENSURE & CERTIFICATIOI{
67 Forest Street
Marlborough, 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 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).
vFacility/Program Name
Facility/Program Address
Reason for lnspection:
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FACITITY/PROGRAM INFORMATION
lnitial Licensure/ Licensure Renewal Facility/Program Renovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))
INSPECTION INFORMATION
This is to document that the above facility/protram was inspected on:
and determined to be:
v
(Date)
f. tn 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):
Signat Fire Depanment Ofticial
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Rev. 06/25115
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Typed or Printed Name of LocalFIre Department Official
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