HomeMy WebLinkAboutCertification of Local Fire Inspection - Inspection - 129 TURNPIKE STREET 11/25/2019 ITT of PUBLIC HEALTH
DIVISION loN of HEALTH CARE FACILITY
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LICEN URE&CERTIFICATION
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99 Chauncy Street,11th Floor
Instruct . . . to-0mvifip;I COD
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 hones 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 INFORMATION
Facility/Program Name
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Facility/Program Address
Reason for Inspection.
Li ensure Renewal ❑ Facility/Program Renovations
Nursing Home or Rest Home Quarterly Inspection (105 CMR 150.015(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and deter fined to he: (Date)
In compliance with local ordinances 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);
Left
Signature of Local Fi Depairt ent Official
Typed or Printed Name of Local Fire Department official
Rev.0 1 5/15 f
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