Broadway Complaint 3-29-2019 ^�M1IIItA,� V� �Yi � �� r �� • ✓
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CITY OF SALEM, MASSACHUSETTS
m±' BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN,gISALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: �rf ; �` ► Received By:
Complaint Number: 2390 _
Complainant
Address: hone:
IV
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Investigated By: _ Date:
Property Owner/Occupant Name _ _Telephone#: