117 Lafayette Street Complaint 2-6-2019 x gel CITY OF SALEM, MASSACHUSETTS
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,.W�^ BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDENC-ISALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: (� Received By: r CA S'
Complaint Number: 2347
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Address: Phone: —�
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Investigated By: Date:
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