HomeMy WebLinkAboutCert of Local Fire Inspection Sep 2026i(g},
lnstructions: Facilities and programs are to provide a copy ofthis form to their local tire 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).
Shields MRI & lmaging Center of Cape Cod, LLC
FACTUW/PROG RAM TNFORMATION
Facility/Program Name
Facility/Program Address
Reason for lnspection:
2 lyannough Rd, West Yarmouth MA 02573
d
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be:
&
(Date)
ln compliance with local ordinances reBarding 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):
Signature of Local Fire Oepartment Official
/^lt)/i,..
Rev. 06/25l15
Fire.3
Typed or Printed Name of Local Fire Department Of'lcial
DEPARTMENT OF PUBTIC HEAI.TH
DIVISION OF HEALTH CARE FACILITY
LICENSURE & CERTIFICATION
99 Chauncy Street, llt Floor
Boston, MA 02111
CERTIFICATION OF
LOCAL FIRE INSPECTION
lnitialLicensure/LicensureRenewal tr Facility/ProgramRenovations
Nursing Home or Rest Home Quarterly lnspection (105 CMR 150.015(D))tr