2-4 Howard Street Rooming House Inspection 7-18-2007 6, CITY OF SALEM, MASSACHUSETTS
v BOARD OF HEALTH
n 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts
Regulations 410.000 et. Seq. ; State Sanitary Code Chapter II and Article XIII of the City
of Salem Ordinance,undersigned owner/lessor and tenant/lessee of a unit of residential
property, hereby authorize the Salem Board of Health or its authorized agents to inspect
the residence identified below in accordance with the aforementioned statutes,
regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly
authorized the same and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health and its authorized agents from any lose or
injury sustained of whatever nature and description occasioned by my/out absence during
said inspection.
Tenant/Lessee '�N caner/L6ssor
Address Address
Address on unit to be inspected
Date
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
tp 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll www.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts
Regulations 410.000 et. Seq. ; State Sanitary Code Chapter II and Article XIII of the City
of Salem Ordinance,undersigned owner/lessor and tenant/lessee of a unit of residential
property, hereby authorize the Salem Board of Health or its authorized agents to inspect
the residence identified below in accordance with the aforementioned statutes,
regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly
authorized the same and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health and its authorized agents from any lose or
injury sustained of whatever nature and description occasioned by my/out absence during
said inspection.
Terant7Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date
CITY OF SALEM9 MASSACHUSETTS ��
# BOARD OF HEALTH
�f 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 11 l; Code of Massachusetts
Regulations 410.000 et. Seq. ; State Sanitary Code Chapter II and Article XIII of the City
of Salem Ordinance, undersigned owner/lessor and tenant/lessee of a unit of residential
property, hereby authorize the Salem Board of Health or its authorized agents to inspect
the residence identified below in accordance with the aforementioned statutes,
regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly
authorized the same and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health and its authorized agents from any lose or
injury sustained of whatever nature and description occasioned by my/out absence during
said inspection.
r'.e� 14 a A- I
Tenant/Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
S f 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts
Regulations 410.000 et. Seq. ; State Sanitary Code Chapter II and Article XIII of the City
of Salem Ordinance, undersigned owner/lessor and tenant/lessee of a unit of residential
property, hereby authorize the Salem Board of Health or its authorized agents to inspect
the residence identified below in accordance with the aforementioned statutes,
regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly
authorized the same and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health and its authorized agents from any lose or
injury sustained of whatever nature and description occasioned by my/out absence during
said inspection.
Taman Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts
Regulations 410.000 et. Seq. ; State Sanitary Code Chapter II and Article XIII of the City
of Salem Ordinance, undersigned owner/lessor and tenant/lessee of a unit of residential
property, hereby authorize the Salem Board of Health or its authorized agents to inspect
the residence identified below in accordance with the aforementioned statutes,
regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly
authorized the same and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health and its authorized agents from any lose or
injury sustained of whatever nature and description occasioned by my/out absence duri*g
said inspection.
j
Tenant%Less Owner/Lessor
Address Address
Address on unit to be inspected
Date
SALEM FIRE DEPARTMENT Inspec.[date:
Insp.Number INSPECTION AND VIOLATION REPORT Reinsp.Date:
Occupancy Name Occupancy Type
Address Bldg. #Is Yes❑ No❑ Floor/Section Phone
Inspector Name Company# Notifications
❑Health ❑Bldg. ❑Electrical ❑Police
1. Exterior 6. Heating Systems ❑ N/A
fire escapes/decks ❑ Pass ❑ Fail 13 Warn ❑ N/A combustibles ❑Pass ❑ Fail ❑Warn ❑ N/A
proper storage ❑ Pass ❑ Fail ❑Warn ❑ N/A within 5 feet
proper access' 0 Pass ❑ Fail ❑Warn ❑ N/A defective chimney ❑ Pass ❑ Fail ❑Warn ❑ N/A
KNOX BOX ❑ Pass ❑ Fail ❑Warn ❑ N/A defective system ❑,Pass ❑Fail ❑Warn ❑ N/A
- other ❑Pass ❑ Fail ❑Warn ❑ N/A
2. Exits
open property ❑ Pass ❑ Fail ❑Warn ❑ N/A 7. Electrical
exit blocked ❑ Pass ❑ Fail ❑ Warn ❑ N/A defective wiring ❑ Pass ❑ Fail ❑Warn ❑ N/A
exit signs working ❑ Pass ❑ Fail ❑Warn ❑ N/A panels accessible ❑ Pass ❑ Fail ❑Warn ❑ N/A
adequate lighting ❑ Pass ❑ Fail ❑Warn ❑ N/A extension cords:
door(s)locked ❑ Pass ❑ Fail ❑Warn ❑ N/A proper use O Pass ❑ Fail ❑Warn ❑ N/A
signs needed ❑ Pass ❑ Fail ❑Warn ❑ N/A cover plate missing ❑ Pass ❑ Fail ❑Warn ❑ N/A
in need of repair ❑ Pass ❑ Fail ❑Warn ❑ N/A proper fusing ❑ Pass ❑ Fail ❑Warn ❑ N/A
emergency lights ❑ Pass ❑ Fail ❑Warn ❑ N/A other . ❑ Pass ❑ Fail ❑Warn ❑ N/A
other ❑ Pass ❑ Fail ❑Warn ❑ N/A r-- — -—
8. Fire Extinguishers ❑ N/A
3. Fire Alarm System ❑ N/A signs needed ❑ Pass ❑ Fail ❑Warn ❑ N/A
operative CI Pass ❑ Fail ❑Warn ❑ N/A properly mounted ❑ Pass ❑ Fail ❑Warn ❑ N/A
properly labeled ❑ Pass ❑ Fail ❑Warn ❑ N/A proper type ❑ Pass ❑ Fail ❑Warn ❑ N/A
accessible ❑ Pass ❑ Fail ❑ Warn ❑ N/A obstructed ❑ Pass ❑ Fail ❑Warn ❑ N/A
trouble indication ❑ Pass ❑ Fail ❑Warn ❑ N/A need recharging ❑ Pass ❑ Fail ❑Warn ❑ N/A
defective devices ❑ Pass ❑ Fail ❑Warn ❑ N/A other ❑ Pass ❑ Fail ❑Warn ❑ N/A
missing devices ❑ Pass ❑ Fail ❑Warn ❑ N/A
other ❑ Pass ❑ Fail ❑Warn ❑ N/A 9. Sprinkler&Standpipe System
-- ❑ N/A
4. Kitchens valves fabled ❑ Pass ❑ Fail ❑Warn ❑ N/A
10 lb.ABC extinguisher ❑ Pass ❑ Fail ❑Warn ❑ N/A valves accessible ❑ Pass ❑ Fail ❑Warn ❑ N/A
at hazard pressure reading ❑ Pass ❑ Fail ❑Warn ❑ N/A
ext.system operat. ❑ Pass ❑ Fail ❑Warn ❑ N/A FDC clear/capped ❑ Pass ❑ Fail ❑Warn ❑ N/A
roof collect.clean ❑ Pass ❑ Fail ❑Warn ❑ N/A Valves open ❑ Pass ❑ Fail ❑Warn ❑ N/A
system inspected ❑ Pass ❑ Fail ❑Warn ❑ N/A valves secured ❑ Pass ❑ Fail ❑Warn ❑ N/A
hood/duct clean ❑ Pass ❑ Fail ❑Warn ❑ N/A spare head avail. ❑ Pass ❑ Fail ❑Warn ❑ N/A
other ❑ Pass ❑ Fail ❑Warn ❑ N/A heads obstructed ❑ Pass ❑ Fail ❑Warn ❑ N/A
S. Storage other — — ❑ Pass ❑ Fail ❑Warn ❑ N/A
proper labeling 0 Pass ❑ Fail ❑Warn ❑ N/A
proper storage ❑ Pass ❑ Fail ❑Warn ❑ N/A PTN Form *84-Completed Yes ❑ No❑
legal storage ❑ Pass ❑ Fail ❑Warn ❑ N/A fff
other --. ❑ Pass ❑ Fail ❑Warn ❑ N/A #58-Filed Yes❑ No❑
10. Violations Found
Form#16-(Rev.11/93) Copies: White-Fire Prevention Yellow-Inspecting Company Pink-Building Owner/Manager