Philadelphia Beverage Tax – Dealer Notification Dealers of Sweetened Beverages are required to provide notification to Distributors that distributions of sweetened beverages to them are subject to the Philadelphia Beverage Tax. Dealer Information - This notification is being provided by:By signing this notification form, this confirms that the Dealer has provided notification of the Registered Distributor/Dealer as required under Chapter-4100 of the Philadelphia Code. Please ensure you confirm or change the information for the percentage of Sweetened Beverages intended for retail sale in the City of Philadelphia at the bottom of this form. Dealer Signature*Filling in your name here will act as signature for this form.Date of Signature* Date Format: MM slash DD slash YYYY 1. Dealer Name*2. Contact Name*3. Dealer Business Location*4. Dealer Phone*5. Dealer Email* Enter Email Confirm Email Distributor Information - This information is being provided to:6. Distributor Name: Ellis Coffee Company 7. Distributor Contact: Accounts Payable Supervisor 8. Distributor Business Location: 2835 Bridge Street, Philadelphia, PA 19137 9. Distributor Phone: 215-537-9500 % of Sweetened Beverages intended for retail sale in the City of PhiladelphiaWill all products supplied to this Dealer be held out for retail sale in Philadelphia?*YESNOPercentage*If the percentage of products distributed to this Dealer intended for retail sale in Philadelphia is less than 100%, please indicate the correct percentage.EmailThis field is for validation purposes and should be left unchanged.