HomeMy WebLinkAbout881 Rte 28 Mold Complaint 10.21.26001.tif - BOHC-26-75 205679 f Y�►I, TOWN OF YARMOUTH
fro, Health Department
1146 Route 28, South Yarmouth, MA 02664
508-398-2231 ext. 1246 Fax 508-398-0836
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COMPLAINT FORM
Today's Date: I0%a I
Type of Complaint: Rental KFood Hazardous Materials Generalxl
This is a formal request for enforcement of an alleged violation. U,,�The following are facts in the case:
Property Address of Alleged Violation: O e—f?p C(d i a to l
Property Owners Name (s):
Property Owners Mailing Address:
Description of Complaint: A/C � not ChmdQ (k *y (�Q(; a � sV l 9
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(bocv I aA n ant y
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Date (s) of Alleged Violation (s):
Name (s) of Person (s):
The following information is required. Failure to provide your name, address,
and telephone number will result in the Inspector of Health Enforcement
Officer to process the complaint at his/her discretion. (PLEASE PRINT)
Complainant Name: —�kA
Address of Complainant:
Telephone Number: 114 —Q Rv I� J� Email Address:
Preferred Method of Contact (check one): Telephone: 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.
Signature of Complainant: Ofi W
I Prefer to Remain Anonymous: W (check box)