OMB No. 1513-0020  (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
09338001000282

1. REP. ID. NO. (If any)
CT
906

OR
48

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
BR-WI-MOU-15001
3. SOURCE OF PRODUCT (Required)
Domestic
Imported
8. 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)

MINHAS CRAFT BREWERY, MOUNTAIN CREST SRL, LLC
1200-1208 14TH AVE

MONROE WI 53566

4. SERIAL NUMBER (Required)
090080

5. TYPE OF PRODUCT (Required)
WINE
DISTILLED SPIRITS
MALT BEVERAGE

6. BRAND NAME (Required)
AXEHEAD
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
WATERMELON
9. EMAIL ADDRESS
 
10. FORMULA/SOP NO.
(If any)
13
11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)
18. 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. ______
12. NET CONTENTS
1 PT. 8 FL. OZ. (24 FL. OZ.)
13. ALCOHOL CONTENT
11
14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL
16. PHONE NUMBER
(608) 325-3191
17. FAX NUMBER
(608) 325-3198
19. 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.
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.
20. DATE OF APPLICATION
12/04/2009
21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
KATHERINE JONES
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.
23. DATE ISSUED
12/15/2009
24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
Other (APPROVED PENDING FINAL DETERMINATION FROM THE FOOD AND DRUG ADMINISTRATION REGARDING THE ADDITION OF CAFFEINE IN ALCOHOL BEVERAGE PRODUCTS.)
Other (PLEASE REFER TO THE TTB ANNOUNCEMENT REGARDING MALT BEVERAGE ENERGY REFERENCES IN ADVERTISING LOCATED AT WWW.TTB.GOV.)
When new labels are printed, all the mandatory information excluding the alcohol content must appear in printing not smaller than two (2) millimeters. This includes lower case lettering. See 27 CFR 7.28 (b) (1). (List information to be corrected) (NAME / ADDRESS OF PRODUCER.)

STATUS
THE STATUS IS SURRENDERED.

CLASS/TYPE DESCRIPTION
MALT BEVERAGES SPECIALITIES - FLAVORED

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 9.18 inches W X 7.28 inches H


Note: The image below has been reduced to fit the page. See actual dimensions above.
Label Image: Brand (front) or keg collar




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