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THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH of o c 1 146 ROUTE 28 SOUTH YARMOUTH MASSACHUSETTS 02664-4451 Telephone (508) 398-2231 Ext. 1240 — Fax (508) 398-2365
Address - -Unit - Floor Apartment No. 3 No. Sleeping Rooms Name and Address of Owner Type: nnual easonal C) Weekly Max. Occupants 5 No. of Habitable Rooms No. Dwelling or Rooming Units
No. Stories inding Mb@in5 Vio Inspection: CD cheduled üPrior to Occupancy D Complaint Basement: Ü Finished C Unfinished Detect rs: Smoke(s Not Present Carbon Monoxide Not Present Wall
loor C • ing ea g Syste : D Gas, Oil, Electric, Propane lumbing Panel Not Labeled C] anel Labeled a-present Safety Concerns Kitchen Stove lectric CD Gas Appearance of Mold Infestation
Rats, Mice, Roaches or Other Z6ntalners/Covers >€arbage and Rubbish 2Kone Observed Z<rea Clean ZÆÉterior Yard Ü Efi¯erior of House D-C8cks on Doors Egress torm/Screen Door Door Closure
it n Windows ve/Reseal Sealant Base of Shower Ü Top of Tub General Appearance Bedroom 1 D 2 D 3 0 4 05 CJ 6 COMMENTS Base of Tub (Floor) —z c C-cm,l A-BJ C Ked geoQ000/l ODoL— Left
R IKU S e_ : SlylC 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 safety
and well-being of the occupant as determined by 105CMR 410.750 of the code or the authorized inspector (see over). This inspection Report is Si ne and rtified Under the Pains and Penalties
of Perjury. z Inspector SO/1-Z3 Date The next scheduled reinspection Title Time
DATE 4-- z s Address LOCATION ere-e- ACTION/ITEM e see- Field Inspection Notes INSPECTOR FINDINGS Y2.0 zevl E- M o e—T— Foe 24 HRS PASS NEXT SCHEDULED RE-INSPECTION
BEDROOM COUNT/DIMENSIONS kle\en ADDRESS: (Room Locations determined by Front Entry) BEDROOM# DIMENSION LOCATION