OMB No. 1512-0092

OMB No. 1512-0092 (01/31/2009)

FOR TTB USE ONLY

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

APPLICATION FOR AND CERTIFICATION/EXEMPTION OF LABEL/BOTTLE APPROVAL

(See Instructions and Paperwork Reduction Act Notice on Back)

TTB ID

05026001000034

1. REP. ID. NO. (If any)

956

PART I - APPLICATION

2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)

MA-I-509

7. NAME AND ADDRESS OF APPLICANT AS SHOWN ON PLANT REGISTRY, BASIC PERMIT OR BREWER'S NOTICE. INCLUDE APPROVED DBA OR TRADENAME IF USED ON LABEL (Required)

SHELTON BROTHERS
205 WARE RD

BELCHERTOWN MA 01007

3. SERIAL NUMBER (Required)

05CPM4

4. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

5. BRAND NAME (Required)

PECHE MORTEL

7a. MAILING ADDRESS, IF DIFFERENT

6. FANCIFUL NAME (If any)

IMPERIAL COFFEE STOUT

8. EMAIL ADDRESS

9. FORMULA/SOP NO.
(If any)

10. LAB. NO./DATE
(If any)

17. TYPE OF APPLICATION (Check applicable box(es))

a.	CERTIFICATE OF LABEL APPROVAL
b.	CERTIFICATE OF EXEMPTION FROM LABEL APPROVAL "For sale in _______ only" (Fill in State abbreviation.)
c.	DISTINCTIVE LIQUOR BOTTLE APPROVAL. TOTAL BOTTLE CAPACITY BEFORE CLOSURE ____ _____ (Fill in amount)
d.	RESUBMISSION AFTER REJECTION TTB ID. NO. ______

11. NET CONTENTS

1 PT 6.3 FL OZ

12. ALCOHOL CONTENT

9.0

13. WINE APPELLATION IF ON LABEL

14. WINE VINTAGE DATE IF ON LABEL

15. PHONE NUMBER

(213) 291-1688

16. FAX NUMBER

18. SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXED TO THE CONTAINER (e.g., caps, celoseals, corks, etc.) OTHER THAN THE LABLES AFFIXED BELOW, OR (b) BLOWN, BRANDED OR EMBOSSED ON THE CONTAINER (e.g., net contents etc.). THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW. ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGUAGE TEXT APPEARING ON LABELS.
PECHE MORTEL IS FRENCH FOR "MORTAL SIN."

PART II - APPLICANT'S CERTIFICATION
Under the penalties of perjury, I declare; that all statements appearing on this application are true and correct to the best of my knowledge and belief; and, that the representations on the labels attached to this form, including supplemental documents, truly and correctly represent the content of the containers to which these labels will be applied. I also certify that I have read, understood and complied with the conditions and instructions which are attached to an original TTB F 5100.31, Certificate/Exemption of Label/Bottle Approval.
19. DATE OF APPLICATION 01/26/2005	20. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	21. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT WILLIAM SHELTON

PART III - TTB CERTIFICATE
This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
22. DATE ISSUED 02/15/2005	23. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

By 01/03/2006, the label and corresponding formula must comply with TTB TD-21. This final rule places limits on the quantity of alcohol in a malt beverage that may be derived from flavors and other nonbeverage ingredients, and requires an alcohol content statement on the brand label if product contains any alcohol derived from added flavors or other nonbeverage ingredients (other than hops extract) containing alcohol.

STATUS

THE STATUS IS APPROVED.

CLASS/TYPE DESCRIPTION

MALT BEVERAGES SPECIALITIES

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Strip
Actual Dimensions: 8.5 inches W X 5.0 inches H

Note: The image below has been reduced to fit the page. See actual dimensions above.
Label Image: Strip

TTB F 5100.31 (6/2006) PREVIOUS EDITIONS ARE OBSOLETE