HomeMy WebLinkAboutCertification of Local Fire Inspection - Certificate of Inspection - 220 SUTTON STREET 12/9/2019 NT OF PUBLIC HEALTH
DIVISION OF HFALTH CARE FACILITY CERTIFICATION
LICENSURE&CERTIFICATION
LOCAL FIRE INSPECTION
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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 INFORMATION
Facility/Program Name
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Facility/Program Address
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Reason for Inspection:
ao�,Wltial Licensure Licensure Renewal El Facility/Program Renovations
Nursing Horne or Rest Home Quarterly Inspection (105 CMR 150.01S(D))
INSPECTION INFORMATION
This is to document that the above facility/program was inspected on:
and 7deteined 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):
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Signature of Local F Department Official
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Typed or Printed flame of Local Fire Department Official
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