OMB No. 1513-0020
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
19051001001203

1. REP. ID. NO. (If any)
CT
902

OR
29

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
BR-MO-21008
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)

Cinder Block Brewery, Cinder Block Brewery LLC
110 E 18TH AVE

North Kansas City MO 64116

CINDER BLOCK BREWERY LLC (Used on label)
4. SERIAL NUMBER (Required)
190034

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

6. BRAND NAME (Required)
CINDER BLOCK BREWERY
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
HOP MAVEN 14 INDIA PALE ALE STYLE BEER
9. FORMULA
10. GRAPE VARIETAL(S) (Wine Only)
N/A
14. 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. WINE APPELLATION (If on label)
12. PHONE NUMBER
(816) 560-8365
13. EMAIL ADDRESS
 
15. SHOW ANY INFORMATION THAT IS BLOWN, BRANDED, OR EMBOSSED ON THE CONTAINER (e.g., net contents) ONLY IF IT DOES NOT APPEAR ON THE LABELS AFFIXED BELOW. ALSO, SHOW 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.
16. DATE OF APPLICATION
02/20/2019
17. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
18. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
Bryce Schaffter
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.
19. DATE ISSUED
03/20/2019
20. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
A brewer who purchases or otherwise obtains kegs from another brewer shall permanently remove or durably cover the original marks or brands as per 27 CFR 25.144
TTB has not reviewed this label for type size, characters per inch or contrasting background. The responsible industry member must continue to ensure that the mandatory information on the actual labels is displayed in the correct type size, number of characters per inch, and on a contrasting background in accordance with the TTB labeling regulations, 27 CFR parts 4, 5, 7, and 16, as applicable.

STATUS
THE STATUS IS APPROVED.

CLASS/TYPE DESCRIPTION
ALE

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 6.5 inches W X 6.5 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 (06-2016)    PREVIOUS EDITIONS ARE OBSOLETE