23B-046 (75) Told -14101
FIRE CERTIFICATE OF INSPECTION
In accordance with the requirements of General Laws, Chapter 111,
Section 51, this Fire Certificate of Inspection issued by the head of the
local Fire Department certifying compliance with local ordinances is a
prerequisite for an original or renewal license_
c ..I' so L
Name of Hospital
30 tocvs7 S% el elfw
Address of Hospital
was inspected on 1 by -Dire
DATE NAME OF INSPECTOR
I HEREBY CERTIFY THAT THIS INSTITUTION COMPLIES WITH THE LOCAL
ORDINANCES
YES I �J NO
If answer is "NO", indicate violations and recommendations.
Violations:
Recommendations:
ISSUED
Signatura
Head of Local Fire
Dept
INSTRUCTIONS:
FIRE DEPT. TO RETURN TWO COMPLETED COPIES TO HOSPITAL
HOSPITAL TO RETURN ONE COPY TO:
DEPARTMENT OF PUBLIC HEALTH
DIV. OF HEALTH CARE QUALITY
10 WEST STREET, 6TH FLOOR
BOSTON, MA 02111
FIRE.3
DPHCQ121
9/93
DPH 3/94
T Oi T a'd 6SGE Z8S 21t? NOSN I>10 10 A 1000 L2:60 s,00E-60-mt