HomeMy WebLinkAboutcert of local fire inspection Jul 2024DEPARTMENT OF PUEI-IC HEALTH
DIVISION OF HEATTH CARE FACITITY
57 Forest Street
Marlborough, MA 01752
TOCAL FIRE
CERTIFICATE OF INSPECTION
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This request is made under the authority of Mass. G.L. c.62C s.49A.
In accordance with Department ofPublic Health requirements, this Fire Certificate of Inspection is issued by
the head ofthe local Fire Department and certifies tlie facility's compliance with local ordinances.
INSTRUCTIONSI
The Fire Department completes this Certificate oflnspection and returns one copy to the long-term cale facility
The long-term care facility must return the completed copy to:
Department of Public Health
Division of Health Care Facility Licensure and Certification
67 Forest Street
Marlborough, M A 07752
Mayfoser Plac6 Nu6ing & Rehabililation Ccnier
579 Brrd( lslrd Ro.d. WsstYa.mourh. Massachlserts 02673-3200
Name of Facility:
Address ofFacility:
Date of Inspection:
Inspected by:
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Initial Licensure/Change of
Ownership
tr Facility Renovations
A Licensure Renewal X Nursing Home Quarterly
Inspection for CMS Compliance
I IIERN,BY CERTIFY THAT THIS INSTITUTION COMPLIES WITH THE LOCAL ORDINANCES.
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Page I of2 Rev. Fcbruary 2020
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Reason for Inspection:
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If answer is "NO", indicate violations and recommendations.
Violations:
Reco mmendations:
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ISSUEDBY: 4 / -
S ignature
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Pag.2 of2 Revised Fcbruary 2020