As indicated in the file, a hearing involving the above-captioned property was conducted remotely by Zoom webinar on Tuesday, July 20, 2021 before the Fire Safety Code Board of Appeal and Review [hereinafter the Board], pursuant to Rhode Island General Laws [RIGL] sections 23-28.3-5, 42-46-3 and Executive Order.
	Participating at the hearing were the following:
COMMISSIONERS: Chairman Newbrook and Commissioners Pearson, Thornton, ODonnell and Muto.
AUTHORITY HAVING JURISDICTION: Deputy State Fire Marshals David Pastore and James Gumbley of the State Fire Marshals Office.
APPLICANT: Thomas Nangle, Wade Palazini, Richard Charest, Larome Myrick, Kenneth Granger and Gordon Reid.
EXECUTIVE DIRECTOR: W. Keith Burlingame, Esq.

TRAVEL OF THE CASE

1.	This is an Application for Variance filed under RIGL chapter 23-28.3, entitled Fire Safety Code Board of Appeal and Review, and the Administrative Regulations promulgated thereunder.
2.	The Application was filed by Thomas Nangle (authorized representative) of RI DOA / DCAMM, 1 Capitol Hill, Providence, RI dated May 26, 2021.
3.	The Application was received by the Board and File  2021063 was opened on June 11, 2021.
4.	A hearing on the Application was conducted remotely by Zoom webinar on July 20, 2021 at 1:00 PM before the Fire Safety Code Board of Appeal and Review.
5.	After consideration of the application, the testimony of the witnesses and of the entire record presented to the Board, and after carefully reviewing such information, the following votes were taken by the Board:
a.	Preliminary Vote  1 [Violation  16]: a motion was made by Commissioner Thornton and seconded by Commissioner Muto to grant the Applicant the relief as outlined herein.  The motion passed on a 5 to 0 vote;
b.	Preliminary Vote  2 [Violation  4  standard application and retroactivity]: a motion was made by Commissioner Pearson and seconded by Commissioner Thornton to DENY the Applicant the relief requested as outlined herein.  The motion passed on a 5 to 0 vote;
c.	Preliminary Vote  3 [Violations  1, 3, 4, 6, 8 & 12]: a motion was made by Commissioner Pearson and seconded by Commissioner ODonnell to grant the Applicant the relief as outlined herein.  The motion passed on a 5 to 0 vote;
d.	Preliminary Vote  4 [Violation  107]: a motion was made by Commissioner Pearson and seconded by Commissioner Muto to grant the Applicant the relief as outlined herein.  The motion passed on a 5 to 0 vote; and,
e.	Global relief addressing the entire application, incorporating the four (4) preliminary votes set forth above: a motion was made by Commissioner Thornton and seconded by Commissioner ODonnell to grant the Applicant the relief as outlined herein.  The motion passed on a 5 to 0 vote.
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RECORD OF THE CASE

The following documents are part of the administrative record for Appeal  2021063 and are pertinent to the decision rendered:

1.	Variance Application  2021063 dated May 26, 2021 and filed on June 11, 2021.
a.	DCAMM Plan of Action / Variance Request [12 pages] dated July 9, 2021, including:
i.	MED GAS CERTIFICATION REPORTS  ELEANOR SLATER HOSPITAL  ZAMBARANO dated April 12, 2021;
ii.	MEDICAL GAS SYSTEMS Verification Report [NORTH 2E & CENTER 3 NEW ZONE VALVE BOXES] dated 4/6/2021;
iii.	MEDICAL GAS SYSTEMS Verification Report [NEW OXYGEN MAIN LINE SERVICE VALVE] dated 4/7/2021;
iv.	MEDICAL GAS SYSTEMS Verification Report [1st, 2nd, & 3rd FLOORS OXYGEN & VACUUM ZONE VALVES] dated 4/10/2021;
v.	MEDICAL GAS SYSTEMS Service Report [REPAIRED OXYGEN OUTLET STATIONS] dated 4/7/2021;
vi.	5 Year Standpipe Test (2) for 3rd Floor North and 3rd Floor South dated 7/6/21;
vii.	Email from Thomas Nangle [Restoration of Medical Gas at Zambarano Hospital] dated April 10, 2021;
viii.	Email from Larome Myrick [Linen Storage] dated May 17, 2021;
ix.	Granger Medical, Inc. Medical Gas Systems Distribution Piping report [4 pages] dated July 9, 2021;
x.	Email from Thomas Nangle [Supply Storage Policy] dated May 27, 2021;
xi.	Email from Thomas Nangle / Nancy Fogarty [Storage  Zambarano] dated May 10, 2021;
xii.	Email from Thomas Nangle [Communication out to ESH Admin] dated May 12, 2021;
xiii.	Email from Thomas Nangle [Storage] dated May 12, 2021; and,
xiv.	Emails (10) from Donna Doris / Thomas Nangle / Nancy Fogarty [Storage] dated May 5  May 12, 2021.
b.	Jensen Hughes Plan of Action [28 pages] dated July 9, 2021.
c.	Letter of authorization for Thomas Nangle from Carole Cornelison dated May 26, 2021.
2.	State Fire Marshals Office Inspection Report dated April 20, 2021.
3.	Scheduling email to DSFM David Pastore and Thomas Nangle dated June 11, 2021.
4.	State Fire Marshals Office follow-up Inspection Report [including 9-page spreadsheet / NFPA 96 (2014) excerpts / RIGL (1969) Title 23 excerpts / photographs (8)] dated June 25, 2021.
5.	Zoom webinar invitation  86222595439.
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EXHIBITS

The following documents were presented at the July 20, 2021 hearing as exhibits:

1.	None.

FINDINGS OF FACT

	Based on the testimony and evidence introduced at the hearing and a review of the administrative file, the Board makes the following Findings of Fact:

1.	The numbers of the Decision below correspond with those of the June 25, 2021 follow-up inspection report compiled by the State Fire Marshals Office.  The above report was utilized by the Board, the Applicant and the State Fire Marshals Office during the July 20, 2021 hearing on this matter.  Accordingly, the Board hereby incorporates the June 25, 2021 inspection report as its initial findings of fact.  Any modification of the Boards findings, such as correction of a deficiency by the Applicant, shall be noted herein.
2.	The building is an existing 4-story above grade building with a basement level, classified as a health care occupancy [long-term acute-care hospital], consisting of approximately one hundred forty-two thousand two hundred eighty-four (142,284) square feet (gross area) and originally built in 1936.
3.	The building is of Type II (222) construction, has an approved (with deficiencies) fire alarm system with emergency forces notification and is provided with an approved (with deficiencies) automatic sprinkler system.
4.	The facility is operated by the RI Department of BHDDH and is licensed by the RI Department of Health for one hundred eighty-nine (189) patients.
5.	The Board finds that based upon the detailed testimony of the Applicants consultant (Kenneth Granger), that the existing and previously approved medical gas installation consisting of bent-radius piping poses no increase in risk to patient safety or fire safety.  The Board further finds that painted piping poses no distinct hazard to life and therefore NFPA 99 does not retroactively apply, and that the painted piping is no longer considered a violation.
6.	The Board finds that based upon the detailed testimony of the Applicants consultant (Wade Palazini) and the AHJ (DSFM David Pastore) and the totality of the circumstances, that the AHJ has met its burden of showing that the existing and previously approved commercial cooking installation poses an unacceptable degree of risk and that the retroactive application of the provisions of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, (2014 edition) is warranted and authorized.
7.	It is agreed to and stipulated by the parties that the following violations have been corrected at the direction and to the satisfaction of the State Fire Marshal's Office: 5, 7, 9, 11, 13, 15, 17, 19-24, 26, 28-36, 39-46, 50-52, 54-57, 59-61, 64, 67, 70-71, 75-83, 86-87, 90-93, 95-102, 104-106 & 110-112 [total  74 of 112].
8.	There is no objection by the State Fire Marshals Office to the granting of the relief outlined herein.

CONCLUSIONS OF LAW AND
DETERMINATIONS ON VARIANCE REQUESTS

References to NFPA shall mean the National Fire Protection Association; references to the Rhode Island Fire Code [RIFC] shall mean NFPA 1, (2015 edition) as incorporated by reference and amended by 450-RICR-00-00-7; and, references to the Rhode Island Life Safety Code [RILSC] shall mean NFPA 101, (2015 edition) as incorporated by reference and amended by 450-RICR-00-00-8.

1.	COMMERCIAL COOKING: This deficiency/violation will be corrected with the completion of item  4, below.
2.	COMMERCIAL COOKING: This is no longer a deficiency/violation as the large industrial oven in the basement has been taken out of service and decommissioned.  In granting this relief, the Board directs that the oven may remain in its current physical location but may not be utilized in any capacity unless brought into full compliance with all applicable codes.
3.	COMMERCIAL COOKING: This deficiency/violation will be corrected with the completion of item  4, below.
4.	COMMERCIAL COOKING: The Board hereby DENIES the Applicant an outright variance from the provisions of RIFC chapter 50 and NFPA 96, finding that an unnecessary degree of risk exists warranting the retroactive application of the standard and the applicable code provisions cited.  Accordingly, the Board subsequently grants the Applicant a time variance of thirty (30) days from the date of the decision to comply with these provisions by developing and submitting a plan of action for the installation of an approved commercial cooking hood and exhaust system in accordance with the provisions of RIFC chapter 50 and NFPA 96.  The Board further grants the Applicant an additional one hundred fifty (150) days in order to implement the above plan of action, at the direction and to the satisfaction of the State Fire Marshals Office.
a.	In consideration of the relief granted herein, the Board directs the Applicant to develop and implement policies wherein there is no further cooking operations permitted that produce grease-laden vapors until such time that the system replacement has been completed.  Traditional cooking operations such as warming, reheating, boiling water, etc., that do not produce grease-laden vapors shall be permitted during this period.
b.	Additionally, the Board hereby authorizes the State Fire Marshals Office to extend the above timeline for good faith compliance efforts being demonstrated by the Applicant in accordance with the modified provisions of 450-RICR-00-00-1.7.2(X) as follows:
i.	The Board authorizes the AHJ to issue, in writing, up to three (3) extensions of time of not more than six (6) months each, for a period not to exceed eighteen (18) months.  Any time extension shall be requested in writing with good faith compliance efforts and/or justifiable cause being demonstrated by the Applicant. Any AHJ-authorized time extension or denial thereof shall be documented in writing and provided to the Applicant, the Board, the State Fire Marshals Office and the local Fire Marshals Office and subject to future review by the Board.
6.	COMMERCIAL COOKING: This deficiency/violation will be corrected with the completion of item  4, above.
8.	COMMERCIAL COOKING: This deficiency/violation will be corrected with the completion of item  4, above.
10.	COMMERCIAL COOKING: The Board hereby grants the Applicant a variance from the provisions of RIFC section 50.4.7.1.1 by allowing the existing manual actuation device for the kitchen suppression system to remain in use in its current location without modification based upon a structural hardship.
12.	COMMERCIAL COOKING: This deficiency/violation will be corrected with the completion of item  4, above.
14.	COMMERCIAL COOKING: This is no longer a deficiency/violation  see  2, above.
16.	MEDICAL GASES: The Board hereby grants the Applicant a variance from the provisions of RILSC section 19.3.2.4 and NFPA 99 (2015 edition) section 5.2.1.4 by allowing the existing and previously approved medical gas installation [bent-radius piping] to remain in use without modification based upon no increase in risk to patient safety or fire safety.  In granting this relief, the Board finds that all defective valves have been replaced and that all system leaks have been repaired at the direction and to the satisfaction of the State Fire Marshal's Office.
18.	EXTINGUISHMENT: The Board hereby grants the Applicant a time variance of ninety (90) days from the date of the decision to comply with the provisions of NFPA 13 section 8.15.1.2.1 by converting the laboratory  3 closet to a non-accessible, non-combustible concealed space that does not require sprinkler protection, at the direction and to the satisfaction of the State Fire Marshals Office.
25.	EXTINGUISHMENT: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of NFPA 13 section 8.15.7.1 by providing the overhang outside Room 1-1 with automatic sprinkler protection, at the direction and to the satisfaction of the State Fire Marshals Office.
27.	EXTINGUISHMENT: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of NFPA 13 Table 8.6.5.2.2 by providing the pharmacy with additional automatic sprinkler protection, at the direction and to the satisfaction of the State Fire Marshals Office.
37.	FIRE ALARM: This deficiency/violation will be corrected with the completion of item  38, below.
38.	EXTINGUISHMENT: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of NFPA 13 section 8.15 by providing the wooden pump enclosure in the auditorium exit access with automatic sprinkler protection, at the direction and to the satisfaction of the State Fire Marshals Office.
47.	EGRESS: The Board hereby authorizes the reduction of the auditorium occupant load to a maximum of three hundred thirty (330) occupants, based upon existing egress capacity, wherein the cited exit through the stage is no longer a required exit.
48.	EXTINGUISHMENT: The Board hereby grants the Applicant a time variance of two (2) weeks from the date of the decision to comply with the provisions of NFPA 13 by removing all combustible storage from the third floor, at the direction and to the satisfaction of the State Fire Marshals Office.
49.	EGRESS: This deficiency/violation will be corrected with the completion of item  47, above.
53.	CORRIDORS: The Board hereby grants the Applicant a time variance of two (2) weeks from the date of the decision to comply with the provisions of RILSC section 19.3.6 removing all non-compliant combustible storage throughout the facility, at the direction and to the satisfaction of the State Fire Marshals Office.
58.	PROTECTION OF HAZARDS: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of RILSC sections 19.1.1.1.3, 4.6.7.5 and 18.3.2.1.1 by reconfiguring and adapting the existing egress system of the basement corridor at the loading dock in accordance with the Applicants plan of action, at the direction and to the satisfaction of the State Fire Marshals Office.  In consideration of the relief granted herein, the Board directs the Applicant to increase the testing frequency of the existing fire door assembly to semi-annual; to provide approved smoke detection and interfacing with the building fire alarm system; and, to ensure that the emergency power supply to the door closing mechanism is provided by the facilitys life safety generator, at the direction and to the satisfaction of the State Fire Marshal's Office.
62.	STORAGE OF COMBUSTIBLES: The Board hereby grants the Applicant a time variance of two (2) weeks from the date of the decision to comply with the provisions of RIFC section 10.18 by removing all combustible storage from the third floor northeast wing, at the direction and to the satisfaction of the State Fire Marshals Office.
63.	STORAGE OF COMBUSTIBLES: The Board hereby grants the Applicant a time variance of two (2) weeks from the date of the decision to comply with the provisions of RIFC section 10.18 by removing all combustible storage throughout the facility, at the direction and to the satisfaction of the State Fire Marshals Office.
65.	EGRESS: The Board hereby grants the Applicant a variance from the provisions of RILSC section 7.1.5.1(1) by allowing the existing basement corridor headroom (piping projection) at the dishwashing room to remain without modification based upon a structural hardship.  In consideration of the relief granted herein, the Board directs the Applicant to provide padding and high-visibility markings at the affected locations, at the direction and to the satisfaction of the State Fire Marshal's Office.
66.	EGRESS: The Board hereby grants the Applicant a variance from the provisions of RILSC section 7.1.5.1(1) by allowing the existing kitchen storage area headroom to remain without modification based upon a structural hardship.  In consideration of the relief granted herein, the Board directs the Applicant to provide warning signage at the affected locations, at the direction and to the satisfaction of the State Fire Marshal's Office.
68.	EGRESS: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of RILSC sections 19.2.1, 7.1.9 and 7.1.10 by reconfiguring and adapting the existing egress system of the stage door in the auditorium in accordance with the Applicants plan of action, at the direction and to the satisfaction of the State Fire Marshals Office.
69.	FIRE PROTECTION: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of RIFC section 12.3.3.2 by repairing and sealing all penetrations, seams and joints in the heater room ceiling with intumescent caulking, at the direction and to the satisfaction of the State Fire Marshals Office.
72.	PROTECTION OF HAZARDS: The Board hereby grants the Applicant a time variance of two (2) weeks from the date of the decision to comply with the provisions of RILSC sections 19.1.3.10 and 13.4.6.11 by removing all non-approved curtains and scenery from the stage, at the direction and to the satisfaction of the State Fire Marshals Office.
73.	Based upon the testimony of the Applicant that all props and materials have been removed, this deficiency/violation has been corrected (to be verified by the State Fire Marshal's Office).
74.	CROWD MANAGERS: The Board hereby grants the Applicant a time variance of ninety (90) days from the date of the decision to comply with the provisions of RILSC section 13.7.6 by providing approved crowd manager training to appropriate personnel, at the direction and to the satisfaction of the State Fire Marshals Office.  In consideration of the relief granted herein, the Board directs the Applicant to provide this training prior to any future assembly events taking place.
84.	EGRESS: The Board hereby grants the Applicant a time variance of one hundred eighty (180) days from the date of the decision to comply with the provisions of RILSC section 7.2.2.4.6.2 by providing approved stairwell landing guards, at the direction and to the satisfaction of the State Fire Marshals Office.
85.	EGRESS: Duplicate of  84.
88.	EGRESS: The Board hereby grants the Applicant a variance from the provisions of RILSC section 7.1.3.2.1(9) by allowing the existing stairwell closets to remain in the current locations based upon a structural hardship.  In consideration of the relief granted herein, the Board directs the Applicant to remove all storage, install No Storage signage and to lock and restrict access to the closets by authorized personnel only, at the direction and to the satisfaction of the State Fire Marshal's Office.
89.	EGRESS: The Board hereby authorizes the reduction of the Lincoln Almond Library occupant load to a maximum of forty-nine (49) occupants, allowing the existing door swings to remain without modification.
94.	INTERIOR FINISH: The Board hereby grants the Applicant a time variance of ninety (90) days from the date of the decision to comply with the provisions of RILSC sections 19.1.3.10, 13.3.3.1 and 10.2 by treating the wood paneling in the faculty lounge with an approved intumescent finish to attain a Class C rating, at the direction and to the satisfaction of the State Fire Marshals Office.
103.	SEPARATION: The Board hereby grants the Applicant a time variance of ninety (180) days from the date of the decision to comply with the provisions of RILSC sections 19.1.3.1 and 6.1.14.1.1 by reconfiguring and adapting the existing egress system of the tunnel in accordance with the Applicants plan of action, at the direction and to the satisfaction of the State Fire Marshals Office.
107.	OPENING PROTECTIVES: The Board hereby grants the Applicant a time variance of sixty (60) days from the date of the decision to comply with the provisions of RIFC sections 4.5.8.1, 12.4.1 and NFPA 80 by completing and addressing all deficiencies set forth in the annual door inspection report, at the direction and to the satisfaction of the State Fire Marshals Office.
108.	EXTINGUISHMENT: This deficiency/violation has been corrected by the removal of the canopy.  The Board further directs that the canopy may only be re-installed when fully compliant with all applicable codes.
109.	EGRESS: This deficiency/violation will be corrected with the completion of item  47, above.

Any deficiency understood by the Board to have been corrected, which is not so corrected, shall be immediately corrected by the Applicant.  The term approved, as used herein, is understood to mean in accordance with the specific provisions related to the particular subject as are contained in this Code, or as approved in particular by the Authority Having Jurisdiction (State Fire Marshal, his or her designated Deputy State Fire Marshals and/or Assistant Deputy State Fire Marshals).

STATUS OF DECISION AND APPEAL RIGHTS

1.	This Decision constitutes a final order of the Fire Safety Code Board of Appeal and Review as set forth in RIGL section 42-35-12 and represents a comprehensive, integrated plan of fire safety for the above-captioned facility under the above-cited use or occupancy.  Accordingly, every variance granted is conditioned upon the Applicants timely and continued compliance with all of the directives of the Board.  Every variance granted is further conditioned upon the continued use or occupancy of this facility under the above-cited classification reviewed by the Board.  [See: Fire Safety Code [FSC] section 450-RICR-00-00-1.7.2(V)].
2.	Failure of the Applicant to initially comply with the full Decision of the Board, within the stated time frame, shall void all variances granted herein.  [See: FSC section 450-RICR-00-00-1.7.2(W)].  In the event of complete, timely and continued compliance with the full Decision of the Board, the above cited variances shall be deemed to have vested in the above-captioned facility.  As long as this facility is in continued compliance with the full Decision of the Board, the above-cited variances shall remain with this facility in the absence of any change in use or occupancy mandating review under a separate classification of the FSC or a revision of the above-cited classification.  [See: FSC section 450-RICR-00-00-1.7.2(X)].
3.	Such changes in use or occupancy of this facility, or failure to continually comply with the Boards Decision shall void all variances granted under the above-cited use or occupancy.  If such change creates a new use or occupancy as outlined in RIGL section 23-28.1-6, all variances granted under the original use or occupancy are void and this facility shall be reviewed under the newly created use or occupancy.  [See:  FSC section 450-RICR-00-00-1.7.2(Y)].
4.	In accordance with RIGL section 23-28.3-5(e), any person who violates a final order of the Board may be subject to prosecution in the District Court with possible imprisonment for a term not exceeding one (1) year, or fined not more than one thousand dollars (1000) for each offense.
5.	In accordance with RIGL section 42-35-12, the Applicant may appeal the Boards Decision, within thirty (30) days of the mailing date of this Decision, by commencing an action against the State Fire Marshal in the Sixth Division of the District Court.  [See: FSC section 450-RICR-00-00-1.7.2(R)].  Commencement of such an action does not operate as an automatic stay of this Decision [See: RIGL section 42-35-15(c)].