HomeMy WebLinkAboutcert of local fire inspection Aug 2026lnstructions: 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 renewint 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).
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DEPARTMEI{T OF PUELIC HEALTH
DIVISION OF HEATTH CARE FACIL]TY
LICENSURE & CERTIFICATION
57 Forest Street
Ma MA 01752
FACITITY/PROGRAM INFORMATIONIt /o,{/o u.. ,//u.r,uLr) COrlFacility/Program Name
Facility/Program Address
Reason for lnspection:
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lnitial Licensure/ Licensure Renewal Facility/Program Renovations
A 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:
8 )0 hod 6
(Date)
ln compliance with local ordinances regarding fire prevention and safety.
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Not to be in compliance with localordinances regarding fire prevention and safety. The following
violations were observed (list violations, or indicate if a list of violations is attached):
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Signature of Local Depanment Official
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Re!. 06/25115
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Typed or Printed Name ot Local Fire Department Official
CERTIFICATION OF
LOCAT FIRE lNSPECTION
INSPECTION INFORMATION
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