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4100 – Safe Body Art
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PR0537638
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COMPLIANCE INFO
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Entry Properties
Last modified
6/16/2023 4:14:53 PM
Creation date
5/5/2023 10:31:06 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0537638
PE
4110
FACILITY_ID
FA0021679
FACILITY_NAME
LIVING WATER STUDIOS (PAK, SOPHOLLIE)
STREET_NUMBER
210
Direction
N
STREET_NAME
MAIN
STREET_TYPE
ST
City
MANTECA
Zip
95336
CURRENT_STATUS
01
SITE_LOCATION
210 N MAIN ST
P_LOCATION
04
QC Status
Approved
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SJGOV\cfield
Tags
EHD - Public
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San Joaquin County <br /> Environmental Health Department DIRECTOR <br /> Linda Turkatte,REHS <br /> 1868 East Hazelton Avenue <br /> Stockton, California 95205-6232 PROGRAM COORDINATORS <br /> Robert McClellon,REHS <br /> :. <br /> Jeff Carruesco,REHS, RDI <br /> c•. — p Kasey Foley,REHS <br /> Website: www.sjgov.org/ehd <br /> 9��FOR 209 468-3420 Rodney Estrada,REHS <br /> Phone: <br /> ( ) Adrienne Ellsaesser,REHS <br /> Fax: (209) 464-0138 <br /> Hepatitis B Declination Statement* <br /> The following statement of declination of hepatitis B vaccination must be signed by an <br /> employee who chooses not to accept the vaccine. The statement can only be signed by the <br /> employee following appropriate training regarding hepatitis B,hepatitis B vaccination,the <br /> efficacy, safety, method of administration, and benefits of vaccination, and that the vaccine and <br /> vaccination are provided free of charge to the employee. The statement is not a waiver; <br /> employees can request and receive the hepatitis B vaccination at a later date if they remain <br /> occupationally at risk for hepatitis B. <br /> Declination Statement <br /> I understand that due to my occupational exposure to blood or other potentially infectious <br /> materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the <br /> opportunity to be vaccinated with hepatitis B vaccine, at no charge to me;however, I decline <br /> hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be <br /> at risk of acquiring hepatitis B, a serious disease. If, in the future I continue to have occupational <br /> exposure to blood or other potentially infectious materials and I want to be vaccinated with <br /> hepatitis B vaccine, I can receive the yaWination series at no charge to me. <br /> Employee Signature: Date: ZZ�Z I <br /> *Taken from: Bloodborne Pathogens and Acute Care Facilities. OSHA Publication 3128, (1992). <br />
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