11 CHURCH STREET, #508 COMPLAINT 12-21-15 ;yF�\WI
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CITY OF SALEM, MASSACHUSETTS
+nin t BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4`FLOOR
• MAYOR FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(5)SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 2112D1S Time: 3,� 5 Received By:
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Complaint Number. 1384
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Complainant o r per,
Address: ee. 5 Phone: — ' —
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Investigated By: Date:
Property Owner/Occupant Name Telephone #:
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