HomeMy WebLinkAboutComplaint - Swan Pond dumpingRAl€!
Property Address of Alleged Violation:
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TOWN OF YARMOUTH
Health Department
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1246 F ax 508-398-0836
COMPLAINT FORM
's Date: /O/c/PC,
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Today
Type of Complaint: Rental Food Hazardous Materials General
This is a formal request for enforcement ofan alleged violation. The following are facts in the case:
Property Owners Name (s):I s\ru, A(
Property Owners Mailing Address:2-'1 frcrnJ, tsak</- <l-
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Description of Comp laint:hruft't *t -T15,t W-i,^(ka41-
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Date (s) of Alleged Violation (s):/o I c,(>"t
Mtshva Wl$Lrl*-Name (s) of Person (s)
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The following information is required. Failure to provide your name. address,
and telephone number will result in the Inspector of Health Enforcement
Officer to nrocess the co InDlaint at his/her discretion. (PLEASE PRINT)
Address of Complainant:
Telephone Number:Email Address:
Preferred Method ofContact (check one):Telcph()ne: Email:
I am basing my allegations on the above facts. I understand that as the complainant, in the event the Assistant
Health Director is personally unable to bring the matter in to compliance, I may be required to attend legal
proceedings to enforce the regulation referenced above in a court of law. Pursuant to the above allegations I am
requesting an investigation and enforcement if applicable.
I Prefer to Remain Anonymous: [ ] (check box)
Complainant Name:
Signature of Complainant: