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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
1146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451
Telephone (508) 398-2231, Ext.124A - Fax (508)398-2365
Apartment No.-Max. Occupants o. of Habitable Rooms-Floor
No. Sleep ng Booms
Name and Address of Owner
Type: n Annual Seasonal C Weekly
lnspection: E Scheduled
Basement: ! Finished
No. Dwelling or Rooming Units No. Slories ----J-2-
::
Finding Vro
Delectors: ! Smoke(s) Nol Present E Carbon Monoxide Not Present Ei?resent
ffisaranceolMold
arbage
n ! Rals, Mice, Roaches or Other
and Rubbish E-e6-oniainers/Covers
Prior to Occupancy ! Complaint
nfrnished
ectric ! Gas
one Observed
l'fr'ea Clean
tr aflattf,/Floo r E-C6iiing
t #@svste., lrt1as, o,t,Erectric, Propane
E-flumb'ng
f safety Concerns
B{/itct en stove
6alca n Panel Not Labeled anel Labeled
E-Ededot Yard xterlor ol House
B-t6'-clii on Doors E-€-gress
t'Storm/Screen Door
E-t(I6hen
losure B-vVii6ws
f Rem al Sealant Base of Shower ! Top of Tub tr Base of Tub (Floor)
eneral Appearance
Bedroom D1 tr2 !3 !4 D5 l6
CON4MENTS
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! A Copy of "Tenants Rights' Has Been Issued to Tenant,
One or more of the violations checked above is a condition which may materially impair the health or safely and well-being of the occupant as
determined by 105CMR 410.750 of the code or the authorized inspeclor (see over).
This inspection rs ed Under the Pains and Penalties of Perjury
lnspector Title 4ur,i.Lna ?ez,ra rt-
q
Date
The nexl scheduled reinspectlon
a?Tirne 4.,Z
PM
P t\,4
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