HomeMy WebLinkAboutCertification of Local Fire Inspection - Certificate of Inspection - 6/17/2019 DEPARTMENT T OF PUBLIC HEALTH
DIVISION F HEALTH CARE FACILITY
LICENSURE&CERTIFICATION
99 Chauncy Street,11th Floor
Boston,MA 0 111
Instructions: Facilities and programs are to provide a copy of this form to their local Fire Department when
requesting a fire inspection for li ensure 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 L
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 INFORMATION
Facility/Program Name � �' � 5T 6AV16
Facility/Program Address
Reason for Inspection:
M/0'0�lnifial Li nsure Li censure Renewal Facility/Program Renovations
Nursing Horne or Rest Home Quarterly Inspection 10 MR 1 . 15(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and determined to be: (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):
Signature of local F e Department Official
Typed or Printed Name of Local Fire Department Official
Rev.0 /25/1
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