HomeMy WebLinkAboutcert of local fire inspection Oct 2024(@,
DEPARTMENT OF PUBTIC HEALTH
OIVISION OF HEALTH CARE FACILITY
UCENSURE & CERTIFICATION
67 Forest Street
Ma MA 01752
CERTIFICATION OF
LOCAL FIRE INSPECTION
lnstructions: Facilities and programs are to provide a copy of this form to their local Fire Department when
requestinB 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).
FACI LITY/PROGRAM INFORMATION
Facility/Program Name {-+u {h,./.,1, /o/_,,1;"u
Facility/ProgramAddress 3Cl i<] a I Ntlt \/*rrrouftl
Reason for lnspection:
E lnitialLicensure/LicensureRenewal n Facility/ProgramRenovations
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:
/o-1- eL/
(Date)
Y tn co.pliance with local ordinances regarding fire prevention and safety
-
Not to be in compliance with local ordinances re8arding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
^t {^", tAtr t{ fl'lr:4rloru SA"ulrr L, v7or.k)
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L't
Rev.06i25/15
Firc.3
Typed or Printed Name of Local Fire Depanment Official
INSPECTION INFORMATION
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Signature of Local Fire Depanment Oflicial
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