OMB No. 1513-0020

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

09356001000171

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

906

PART I - APPLICATION

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

BR-OR-LAU-15000

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)

LAURELWOOD PUBLIC HOUSE & BREWERY, LAURELWOOD RESTAURANTS INC.
3804 NE HASSALO ST

PORTLAND OR 97232

4. SERIAL NUMBER (Required)

091222

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

ORGANIC PORTLAND ROAST

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

ESPRESSO STOUT

9. EMAIL ADDRESS

10. FORMULA/SOP NO.
(If any)

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. ___09028001000226___

12. NET CONTENTS

1 PT. 6 FL. OZ. (22 FL. OZ.)

13. ALCOHOL CONTENT

6.3%

14. WINE APPELLATION IF ON LABEL

15. WINE VINTAGE DATE IF ON LABEL

16. PHONE NUMBER

(503) 282-4948

17. FAX NUMBER

(503) 282-4280

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 12/22/2009	21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT CHAD KENNEDY

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 01/13/2010	24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

Approval based on certification by the Accredited Certifying Agent (ACA) and subject to compliance with the Organic Foods Production Act of 1990 and the National Organic Program Regulations at 7 CFR Part 205, administered by the U.S. Department of Agriculture- Agricultural Marketing Service

STATUS

THE STATUS IS APPROVED.

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: 5 inches W X 4.5 inches H

Label Image: Brand (front) or keg collar

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