HomeMy WebLinkAboutCert of Local Fire Inspection Oct 2025.@
DEPARTMENT OF PUBLIC HEALTH
DIVISION OF HEALTH CARE FACILIW
TICENSURE & CERTIFICATION
99 Chauncy street, 11th Floor
goston, MA 02111
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).
Facility/Program Name Shields MRI & lmaging Center of Cape Cod, LLC
FACITITY/PROGRAM INFORMATION
Facility/Progra m Add ress 2 lyannough Rd, West Yarmouth MA 02673
Reason for lnspection
il lnitia I Licensure/ Llcensure 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/program was inspected on
and determined to be:Date)
Signature of Loc re Department official
ZA
{^compliance with localordinances 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):
)35
L'l- oi*,',
Rev. 06/25115
Fire.l
Typed or Printed Name of Local Fire Department Official
CERTIFICATION OF
TOCAT FIRE INSPECTION