Wappinger Elks 2609
I
GC-5
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
GC -lliJ - CililiJ- ~ - ~
N.Y.S. Identification Number
I
NYS RACING & W AGERlNG BOARD
] Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (5] 8) 395.5400 Fax (5] 8) 347.] 469
www.racing.state.ny.us
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 II
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity. Patriotic. Youth. Educational
Names of Members in Charge
Dana Mills
Joan Mills
Zip Code: 12590
Derrik Mills
Rich Desruisseaur
LICENSE PERIOD
DATE
2007
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF GAMES
EACH GAME (Starting Bank)
NUMBER OF WHEELS
EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by Town' of Wappinger
(Name of Municipality)
Town Clerk
(Title of Authorized Officer)
(Date)
Authorized Officer)
11111111111111111111111111111 .J
4/11/2007
L BJ-GC.5 (Rev. 3/06)
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
April 12, 2007
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
BELL JAR LICENSE -Wappinger Elks #2609 - 2007
Please find enclosed the GC-6, GC-5, and GC2A - Amended Bell Jar for the Wappinger
Elks #2609 for the year of 2007.
9!cc.
c. Ma erson
Town Clerk
Town of Wappinger
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
April 12, 2007
Ms. Dana Mills
17 Pawley Lake
Pawling, New York 12564
TOWN CLERK'S OFFICE
20 MIDDLE BUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
Re: Amended Bell Jar License
Wappingers Elks #2609
Dear Dana:
Enclosed please find your GC-5, GC-6 and GC-2A - Amended Bell Jar
License for the year 2007.
Please do not hesitate to contact me with any questions you may have
at 845-297-5771.
Sincerely,
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
r
GC-6
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
APPLICATION TO AMEND
(PLEASE CHECK)
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
-,
"""!f~
I.':> ,'^_ .
i~G:::,i~ ~
.~:7~;~;;~~~ ,<~
,. .\ f'~. I. "'I'~\"
Must be conspicuously displayed along with License (GC-5)
~
Date
i (FOR OFFICE USE ONLY)
$1 /
Fee Received
(only if applicable)
GC-rn-IilII9J-I~loILI-~ I (SlO'L
N.Y.S. Identification Number Present License Number
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
.~
County
J25GO
Zip
~
County
,?~
Zip
Application is hereby made to amend the above numbered license. The amended information is contained in the schedules which are
checked below and attached, and are to replace the schedules previously filed.
pc Schedule 1.
~ Schedule 2.
o Schedule 3.
,SSchedule 4.
o Schedule 5.
o Schedule 6.
o Schedule 7.
Officers And Directors
Members In Charge Of Games
Auxiliary/Affiliate Organizations Assisting At Games
Assistants To Members In Charge Of Games
Dates, Hours And Rent Of All License Periods To Be Held
Expenses
Types of Games
If any other information furnished on original application is to be changed, show amended data below.
L BJ-GC-6 (Rev. 3/06)
Page I of2
IIIII111111111111111111111111 .J
I
I
I swear (or affinn):
I. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the
answers contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined
in the Games of Chance Licensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games
are to be held, operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the
N.Y.S. Racing & Wagering Board and local licensing ordinances or laws, will be present at all times, in charge and primarily
responsible for the conduct of games.
4. That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the terms
ofthe license, the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering
Board and with the provisions of local licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions ofthe Games of Chance Licensing Law as amended, the Rules
and Regulations ofthe N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary, compensation, reward or recompense will be paid to any person for holding or assisting in the operating
or conducting ofthe games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by
the N.Y.S. Racing and Wagering Board.
~/rn/[Q}ZJ'Jk~
Date Signature of the Head of Organization
~L ,,-,,4J"'
Print Name
STATE
OF
NEW YORK
}ss
COUNTY
OF
/)u.7UlJS
~J-J6
CITY /TOWNNILLAGE
OF
/) ~t!.1L J-I LLL,.,f being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
~ .
Sworn to before me this / I day of ,4!J1Lt..-l- , 20 ~
~.~~
Notary Public
SignefLJl~
Commiss~pfj?n6'RTON
Notary Public, State of New York
Reg. # 01 N0604:S43
Qualified in Dutchess County
My Commission Expires June 19, 20 LtJ
My Commission expires
J2L.v~ /0
,20~
To be completed by Municipal Clerk:
Issued by
(Name of Municipality)
(Title of Authorized Officer)
(Signature of Authorized Officer)
(Date)
L BJ-GC-6 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 ~
,-
GC-2A
I
APPLICATION FOR GAMES OF CHANCE LICENSE
""iii.'
":~~;~1<~
~~ cJ:>l"+";, .:.{
T _\l-J..I.~10\l .
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
l?
GC- liE - [!Jili] - ~ -1012.1011 I~I
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of biI1h of all officers.
If organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE ~AME DATE OF BIRTH STREET ADDRESS CITY ZIP , I
[tailed 1<1>\01 ~t 1-1 tI b ID / DB / ~ 117 1Owli"'iIo!:"e.I1?;wlt '"'i-1/25t.L!
ltM,,,'1 ~+I_ 6ee.t'o'"lLll2. / 10 / 1./51" R;\'Illh~ Ilbwl'1r Ilz~
~\~I)-\~t. "X IOq 1 ~/S11287i~~_ I~e/ H }ZSg~
~+ ~rc~. 104/2.5/~I~C.~ 5LA_1~~V'\~I'l'5~L
~l.)I~ 1 I 1 1 I 1 I
~In 1fattu.1l'C 1?ohh~lo4/~/'-IC> 16'~8"l)~~~1 ~
~~~-rt 1_1_I_n:o~\\ LD I~\\ I,
~___ _ l!:tjJ2!!L/~1 V Vi v:1 In~
T~. I , Yf)~-.JlI J:t5/~1 I IJ2J,fJ~
-rl~ ! 1_1_1_1 1 1
1 1_1_1_1 I I
Attach additional sheet if necessary.
[Q}d] 1 10 I, 11M
Date
SCHEDULE 2:
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
OF BIRTH MEMBrRSHIP STREET ADDRESS ~ CITY . ZIP
I 02 1 J5L/JLI Y 1M 1tJWhY"'9U1te 1 tCwJI~112~
I ~ 1 ZJ.L/~I.5 laRlw\l~ Lon- 11Ow\,nc; i~
I 10 1~/40 I~I~W\(~ Lcl:e Ilbw\,~I~
II 1 C:I!:> 1 ~I LJ I/re~ ~) ki,ro\ ~~ 1 JZI,^~
_1_1_1 I I I
1 1 I I I
-1-1-1 I 1
-1-1-1 1 I
=1=1=1
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ill NUMBER.)
NAME OF AUXILIARY/AFFILIATE
GAMES OF CHANCE ID NUMBER
L BJ-GC-2A (Rev. 3/06)
Page 1 of2
11111111111111111111111111111 -.J
I SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
EMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADD~SS
n: / 2.6 / t./z.. I /5 110 Vcy-~~ JY. I
I~/ az- / 0'1 I L 1-'3 ~rn~Jn Vle&tll
~~ ~'" 109 1l':L/fi I rz. I28Ti90'~' I
~I f1~i~/~/~ I _ lj),o.~54-'7 I
I / / I_I I
1-/-/-1_1 I
1-/-/- I' I
1-/-/-'-1 I
-/-/-1=1 1
1-/-/-1_1 I
1-/-/- 1 I I
'-/-/-1-1 I
1-/-/-1-1 I
'-/-/-1-1 1
1-/-/-'=1 1
1-/-/- 1 1 1
1-/-/-'-1 1
1-/-/-1=1 1
1-/-/-1_1 1
:-/-/-1_1 1
1-/-/-1_' ,
1-/-/-1_1 1
-/-/-'_1 I
-/-/-1 I I
/-/-/-'_1 I
1-/-/-1_1 I
1-/-/-1_' I
1-/-/-1_' I
1-/-/-'_1 I
1-/-/-1_' 1
1-/-/-1_1 1
/-/-/-1_1 1
1-/-/- 1 1 I
/=/=/=1=1 I
L BJ-GC-2A (Rev. 3/06)
Attach additional sheet if necessary.
Page 2 of2
CITY ZIP
o I/Z'ffta
I J z.~ 2.c..t
1/255~
IJ2J5~l-
1
I
I
I
I
I
I
11111111111111111111111111111 -.J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
January 9t\ 2007
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
BELL JAR LICENSE - Wappinger Elks #2609 - 2007
Please find enclosed the GC-2, GC-2A, GC-2B,GC-4, and GC-5 for the Wappinger
Elks #2609 for the year of 2007.
'. r .
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297.5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
~....t <.TV1- ~
{?-I ~/<J7.,
December 27, 2006
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, N Y 12601
~~V\+ ovt
Of, (l(~
+v 5'~/a.
Dear Sheriff Anderson:
Enclosed, please find a copy of the "members in charge" of the Wappingel __ow
#2609, Route 376, Town of Wappinger, who will be selling BELL JAR Tickets on
their premises throughout the year 2007.
I would appreciate your review of the application. Please complete the "Findings
and Determination" form attached and return the completed application to my
office.
Thank you for your attention to this request and your prompt reply.
Yours truly,
~~~
Town Clerk
Town of Wappinger
,
r
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
--,
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC-ru-~-~-~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Name of Applicant Organization
1195 Route 376 Wappingers Falls, NY 12590
Address
After investigation, and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and determinations
have been made:
1. All the members-in-charge designated in the application to condilct games of chance are of good moral 0 Yes 0 No
character and have never been convicted of a crime.
Signature of Person Conducting Investigation
Title
2. . Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant are in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Garnes of Chance Licensing
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense will be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and given will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
IXI Yes DNo
IXI Yes DNo
GQ Yes DNo
fI Yes DNo
IX] Yes DNo
~Yes DNo
IXI Yes DNo
IKI Yes DNo
GO Yes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED 0; license is DENIED 0
Signature of
Filing date of Application Authorized Officer
(Municipal Licensing Authority)
Date
Title
ONE COPY OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC.2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC4 .... '103) I~ 1111~11111II1~lllIIml .-J
r
GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305.2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
-,
UJB]/[lE]/[QIb]
Date
Sa" , .
-ne..S.
~I \:2\JVl'leS
I
ZIP
IjJJ'9b
IV ISh
I, c9.
Q; 11.96:53
. [f!Js31
11 8 bO.5
1 JiJS-t}D
f) erS 1 /.J)s9b
eJ 1f).bO~
Il~ 5" 1t>
I
SCHEDULE 2: MEMBERS IN'CHARGE OFG.AMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPliCANT ORGANIZATION)
DATE YEARS OF
~ NAME 1 OF BIRTH ~BJP S~T ADDRES;; CjTY ZIP
-"ll YI(l \11; 1,g I Qfl / A / :1o.J I 1 i'-( \.'tlwl, n~ La..ke.. l1nuJh (1 I I :J.!,7,f.
...........~~I-1L/~/iJ!L1 s I ~~l,~ wi,,, I~
IDLLlt:LLISl;L1 Cf I, llis i"{h'r. 1 .' I~
\i ' S €au I-.lLI Otr 13.L1~1 1/~3 fbd (hvdn\al~1~1'c9bD3
1_1_1_1 I I I
1_1_1_1 I I I
1_1_1_1 I I I
1_1_1_1 1 I I
1_1_1_1 1 I I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFIlJATES. EACH AUXIUARY/AFFll.IATE LISTED MUST HA VB ITS OWN ID NUMBER.)
NAME OF AUXILIARY/AFFILIATE
GAMES OF CHANCE ill NUMBER
11111111111111111111111111111 ~
L BJ-GC-2A (Rev. 3/06)
Page 1 of2
I SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all members of applicant organization and members of authorized affiliates and auxili8IY who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
MEMf3ER NAME DATE OF BIRTH MEMBERSHIP STREET ADDtlliSS CITY
-nob;n R~""JkJ 06/ eo /1-/ (); K I It) Vornclva,n b-- I et'1,
~\~ ,lis 1..J!2/12-/!://L .:L I ~I .
" e.- rObYlLLK I o:z , 0:;" '.JJ 1L 1 ~~ rrJOC(lJ2'S1 r/) 'Y1~ I
!1kl,\< Cif I~j lL.rn JR. .a.a :L.q.e~~1 ~loell.'Je.
'K\1cpne. m[.done.l-'1i. ~ ~ ~ .3 t, .ilL 6,':1 J./e;leo ,;1( e I ~fJl1ge" s
1-'-'- 1
1-'-'- 1
,-,-,- 1
1-'-'- I
,-,-,- I
1='='= - I
1_'_'_1- I
I , , I
,-,-,- I
1='='= 1
1 , , 1
1='-'= _I 1
1_'- , - I I
1_'-'= _I 1
1_'- , - 1 1
1_'-'= _I I
1_'- , - 1 1
1_'-'- _I I
1_'='= - 1 1
1_'_'- _I I
1_'_'_1_1 I
1_'_'_1_1 1
I , , I 1 I
1-'-'-1-1 1
1='='=1=1 I
I , / 1 I 1
1=' "=1=1 I
1_'_'_1_1 1
.
L BJ-GC-2A (Rev. 3/06)
Attach additional sheet if necessary.
Page20f2
I
ZIP
I/Q67()
1 Jlii74
I J Q,~2Y
I r~~-33
II t)'59 0
1
1
I
I
1
I
I
I
I
I
I
I
1
I
1
I
I
I
I
1
I
I
I
I
I
1
I
I
I
11111111111111111111111111111 -.J
BPOELKS ,..,0. 2609
BEll.. JAR ACCOUNT
P.O,'BOX'4?
GC 1;3-219~6Q2-0201;3
WAPPINGER FALLS. NY 12590
~€J~~ OF ~,.) a.d W~//t?1 /llwej2--
vr~.'. 47....~.... c. ......... ?cPj.v~.. ....... :
~TIIE . '.,
BANKOF
yoNEW. 423 SOuth Road
ORK.. POU~~ NY l~!
FOR L-t~~~
DATI;
12-:ltif/~ c
r"'; .
I $~~
#,r,....',:...;'.~
---.00
~~~
.
r
GC-2
-,
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
~~:ts?~S~
BELL JAR
RAFFLE 0
(only raffles wi over $30,000 net profits in calendar year)
,
.'
I FOROFFICE $1 ;)5.1/) I rn I ~ I [Qlli I
USE ONLY Fees Received Date ~
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC -1IJ3J - [&]IN]- [];]QlliJ-~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENT~THIS APrLICATION
-(t s DtL..\.cj,eSS .
al ty County
PART A. GENERAL
1. Name of Or anization
2.
3.
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation..:i!(' 1? ~ \<
. . State incorporated n I /I ) () (
Incorporated ASSOCIatIon 0 \ l .ul. ,
Unincorporated Association 0
State incorporated
Date5J@ I [[] I GHlj
Date[[] I[[] I[[]
Individual
o
5. Did your corporate status change since your identification number was assigned? 0 Yes .~o
6. Are you doing business under a trade name? 0 Y es ~o If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or rame drawing(s) are to be conducted. 11 q'J' ~~~e 3 ^flu ~e.rs /2Sl)
8. Name and address of authorized games of
chance lessor renting to applicant.
'{\) \ ~
9. Does the applicant own the premises? ~ Yes 0 No If "yes", how long?
~~ \\&1("S.
1!1 aJ
~ Q-r'2,-
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? 'f11 Yes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? Yes
o No If "yes", gIve full details.
12. Are the premises or any part thereof
where games of chance are to be played .~ es 0 No
licensed by the State Liquor Authority?
13. Has such license ever been . / If "yes", why? (Explain on a separate sheet, ifnecessary, and attach.)
revoked or suspended? 0 Y es ~No
L BJ-GC.2 (Rev. 3106)
Page 1 of2
111111111.11111 .J
r
I
PART C. PURPOSES OF GAMES
14. State the sp~cific purpo~r "ihich ~eFntire net proceeds are to be d~voted and in wha~lfIDer. I
\. t'O-:+y tt'v.HC-- '\ Du.~ mL{~~OnQ
1 swear (or affirm):
1. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games of
Chance Licensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games are to be held,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering
Board and loca1licensing ordinances or laws, will be present at all times, in charge and primarily responsible for the conduct of games.
4. That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the tenns of the license,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provisions
ofloca1licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary, compensation, reward or recompense will be paid to any person for holding or assisting in the operating or
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
I~J~ [I [ili31 ~ Si;Z~J.g~
~M;!.{A ~. K.)f~6..r
Print Name
STATE
OF NEW YORK
}ss
COUNTY
OF t)~~
OF f:b~~-,~~
CITY rrOWNNILLAGE
~c.lc. l<"k.l~ being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
Sign~Cth~
Commissioner of Deeds
Sworn to before me this
....
I' day of t:w:c..... 20 .12lL..
My Commission expires
Notary Public
NoLt.2c..I"'"
, 20 0 'i
EMILY C. ROBrSCH
Notary Public. State of New York
No 01 R05088607
Qualified in Ulster COLl~.
Commission Expires Nov. 24, ..!:t:!:!..I.I:
L BJ-GC-2 (Rev. 3106)
Page 2 of2
IUIIIIIIIIIIIIII -1
r
GC-2A
I
APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
lJ Cl. I r"
Name of Organization
GC- [LE] - [[L[] -I b 10 1& I ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organi2ation is a corporation, or an incorporated or unincorporated association, list officers and directors.
._I;r!I;L~ I. . NAME' DATE OF BIRTH STRE T.1ADDRESS <"? CITY ZIP
c~i e yi~1 01 1.6a1 . 7e.V. 1 "ill . 1t!f9b
'I I.J.CL I t; B I ':/.l2.J Lrf ~~,kf (I f'( I 5b
1 I I 9 I JD IIJS...I h'1 R1wlln~ Lake. 1 wi I n I/J>.
I j'l11)<\{ f4 I Ql[/ l.i:L/Q1 I19J:rt" -, ~ I " IIB633
I \)Qn C) ~ 1{l[J&:L/~I.. ~M!LJ=~ f!1L;31
.dl1e1L/~1~1 .1 18bOj'
IQ!:ua~.J"&JrPd I I ltl.5-tJO
, \ 1C6/flJL/':iJLI_~~(~I.r~II'!)S9b
-r\e.s, ~ e~1 Q~-' aiLl___ _~~.lJ eJ If).b03
~1~\Jl'l1es 1..lL/~/&11-Y-1~V'e'l]E)~<llb e. Il~5'1D
I 1_/_1_1 1 I
Attach additional sheet if necessary.
UiJ I [ill] 110 Ib I
Date
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
, NAME I OF BIRTH MEMB;.fRSHIP S~ET ADDRESS CfTY ZIP
Th~(l y(1;' s I QIlI J!LI :112.1 I I "f ~nW'\n9 LoJ<e...1 mwlr n i 1:J~bi
<--""~e!~; " I ~ / (liLJ 'i.!L I ...,- I I (\. /, '" I ~
I dfLlQ.LI;5?;L1 q I It illS Q r. I. ~ I~
I:i' -<;>. eo.ur 1-1L / OtT /aL I Gl I /8 vd I clI ~ I J Ol/'n.1
I I I 1 I I I
1-/-1-1 1 1 I
1=/=1=1 I I I
I I I 1 I I I
1=/=1=1 1 I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXll.JARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HA VB ITS OWN ID NUMBER.)
NAME OF AUXILIARY/AFFILIATE
GAMES OF CHANCE IDNUMBER
L BJ-GC-2A (Rev. 3106)
Page lof2
11111111111111 .J
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
M,EMJlER NAME DATE OF BIRTII MEMBERSHIP STREET ADDllliSS CITY
nd:lxl R~q",kJ 061 80 I~ I K I In Vorndyqn.k. I
~X\~ II~I-'Q-' iLl!-I.tL I :L I ~I
sieve. fobY'QK 1 0;;' 'o:Z , ~ ILl <'~ fY1ct.C1lSH1) y,eL I
nKh1((ot I_cl) 12::) nl H I &.a::L..q~~9L-1 Hqicell.k
~uroe. ~mf?1.IDn~I121'-'~' 3t:, I L8- 1 5:~ J..(eJefJ ,~"e I LllofIVXjel/s,
, I , , I 1 1---==-t1
1-'-'-1-1 I
1-'-'-1-1 1
1-'-'-1-1 I
1='='=1=1 1
I , , I I 1
1-'-'-1-1 1
1-'-'-1-1 1
1-'-'-1-1 I
1='='=1=1 I
1_'_'_1_1 1
1_'_'_1_1 1
1_'_'_1_1 I
1 , , I 1 1
1-'-'-1-1 I
1='='=1=1 I
I , , I I 1
1-'-'-'-1 1
1='='=1=1 I
1 , , I I I
1='='=1=1 I
I , , I 1 1
1-'-'-1-1 1
1-'-'-1-1 1
1='='=1=1 I
1_'_'_1_1 I
1 , , 1 1 I
1='='=1=1 1
1_'_'_1_1 1
I
ZIP
I iQ6'JO
I~
I, Q6-2~
I, r;J ::)-33
II [}tJ-9 0
I
1
1
I
I
I
I
1
I
1
I
I
\
1
I
1
I
I
1
I
I
I
1
1
I
I
1
I
1
1III1III1II .J
L BJ-GC-ZA (Rev. 3106)
Attach additional sheet if necessary.
Page 2 of2
r
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395.5400 Fax (518) 347-1469
www.racing.state.ny.us
I
GC- rn - [iliID - ~ ~
NYS Identification Number
G.i]/[ill]/rn
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
RENT
.am/pm 1$. "
,am/pm '$. ,-,
.am/pml$. ,-,
.am/pm ! $. .'
.am/pm ! $, "
,am/pm 1$ .-,
,am / pm I $ .'
,am/pm 1$. ,-.
,am/pm 1$. "
.am/pm 1$. "
.am/pm !$ , ,-,
,am/pm !$ , .'
DATE HOURS
/ / I ,am / pm -
, , , 0- . . . . .
/, / I .am / pm -
, . , .' .'
/. / I ,am / pm -
. 0 , . ,-, "
/ / I .am / pm -
, , , . , ,., .'
/, / I ,am / pm -
, , , , . ,-, "
/ / I ,am / pm -
0 . , . , . . . . ,.,
/ / I .am / pm -
, , " .'
/ /. I ,am / pm -
. , 0 0 , o. . o'
/ / I .am / pm -
, 0 . .' . . .
/ / I .am / pm -
, . . . . . .
,/ / ,am / pm -
, , 0 , " ,-,
/ / .am / pm -
. . . " ,-,
RAFFLES
DATE TIME
..,
.am /pm
.am /pm
am / pm
,
am / pm
.
.am/pm
PRIZES (Cash or Fair Market
Value of Merchandise)
!$ . .
1$. ,'.
1$. .-,
!$ .'
!$
am / pm -
am/pm -
.am/pm -
am / pm -
. .
am / pm -
. .
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
/
,/
/
./
/
I
. I .
I
I
I
I .
I
. I .
I
.'
.-,
/
./
/
./
/
,-,
,-,
,-,
,-,
.-,
. I .
.-,
. . .
STATE
ZIP
L BJ-GC-28 (Rev. 3106)
Page 1 of2
IIIIIIIIIIIIIIII~~ ..J
r SCHEDULE 7 TYPES OF GAMES -,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve2as Nie:hts and Bazaars only: The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE A WARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $
at $
at $
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A~EL JAR
LICE
YES NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESD NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC-2B (Rev. 3106)
Page 2 of2
1111111111111111 -.J
...~ ~~.
r
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext.. Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - rn - ~ - [ITili] - rniliIiJ
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Name of Applicant Organization
1195 Route 376 Wappingers Falls, NY 12590
Address
e General Municipal Law, the following findings and determinations
After investigation, and a hearing if required under Sec. 192
have been made:
1. All the members-in-charge designated in the a
character and have never been convicted of r'
,/
Signature of Person Conducting Investigation' //
Title
2. Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant are in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Games of Chance Licensing
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense will be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and given will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
~es 0 No
IX! Yes DNo
&I Yes DNo
!Xl Yes DNo
fI Yes DNo
IXI Yes DNo
~Yes DNo
IKI Yes DNo
IXI Yes DNo
Qa Yes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result of the findings and determinations stated above, license is GRANTED rn!license is DENIED 0
Signature of
Filing date of Application Authorized Officer -,.
Date 4 ~ 107 Title i7NJ/1 L' el-k-..
ONE COpy OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC.2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ.GC4 (Rev. 4/03) 11111111111111111111111111111 ~
". .t-l
.r
GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
-,
\J (l. I ()
Name of Organization
GC- [ili] - ~ -Ib Ie> 1& I ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation, or an inCOlJlorated or uninCOlJlOrated association, list officers and directors.
-Ki t lTI~r~je '( NAME DATE OF BIRTH STRE hi ADDRESS Q CITY ZIP
c tel I ylJJJ..1 QLI.51L1 f' lex. I \at IJJ!Qb
I 1 LilLI ~211lL1 ~rf ~ (j IV I 5b
I I J9 lID II:!S.-I '1 ~LJm J.a I wiln I/~
I I q:[ / JJi.../..ti 11!n]tl'" , ~ I (! 1/.9.235
I 1D!l. IIli.. I !A. I . . -il. !5J./LI u . ~ 1.!)~31
.dl1Q:L/~1~1 I 18ho3
I In 1Q!:1lflfl_-':!&I~r:B11 '(sed I I J/l,:;-C;O
Sa>. ~ . 105/~.-'~1 .~rXn~I~f) er~II.g)S9c>
-fie.s. i e~/~/a.b..I___~1 eJ If}.b03
~I ~YJVl1eS eoie.v- 1..lL1 ~I Q1...1,3t-\ QrdV'ews ~<LI bel Il~s-.I#>
I ,1_1_1_1 I I
Attach additional sheet if necessary.
UJR]/[ill]/[QJbJ
Date
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST UST AT LEAST FOUR MEMBERS OF APPLICANT ORGANlZATION)
DATE YEARS OF
"" NAME 01 OF BIRTH MEMB;fRSHIP S'fIJ.ijET ADDRES~ CITY ZIP
.\hl'\Q '\11; 1 g I QE./ J.~_J :lQJ . I l'i l"tlwI"'9 Lct.ke..1 ~u.JI, () I t!J.S6f.
~~e!~;'\ 1-.-b../&JiJ!L1 .')- I ~~l,~ I'n I~
I (!)fL1Q....L1 ~I Cf I , llis i"!rr.:-I" I~
\i ' S €Qurl-1L1 QtLI3LI~1 1/~3 ad (hxdn\(tWi~119bD3
1_/_1_1 I I I
I I I I I I I
1=/=1=1 I I I
I I I I I I 1
1=/=1=1 I 1 I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE USTED MUST HA VB ITS OWN ID NUMBER.)
NAME OF AUXILIARY/AFFILIATE GAMES OF CHANCE ill NUMBER
111111111111I1111111111111111 .J
L BJ-GC-2A (Rev. 3/06)
Page 1 of2
ZIP
IIQ6-90
1Jiii74
1 J QS-2~
I f~~-33
II fi'o-9 0
,
I
I
I
I
I
I
I
1
\
I
I
I
,
1
I
I
1
I
I
I
1
I
I
I
I
I
I
1
11111111111111111111111111111 .J
~, ,.
I .1 SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all membelS of applicant organization and membeIS of authorized affiliates and auxiliary who will assist with games. Each pelSOn listed must be a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
M NM4E DATE OF BIRTH MEMBERSHIP STREET ADD~S CITY
n R~..",W 061 eo 1 ~ 1 1S'- I 10 VQl:...{l'Q,n 1 e, '1,
~\~ ,1~1-1QILLI!itL I:L I ~I
. e.- oby\(l I O:Z , 0:2.. , JJ 1 L I ~~ rfJCX"..CAS/ r/) y,dv I
rh"~~ 1~/LLlfll..&-1 ~~~~~I Hqk:dl~
~ U CJ€ne. mRllone..I...D1..' -'!2J' 3 &, 1 LR- I lC ('f] ,<' 1 ~fJt'~ev s .
I I , , 1 I I
1-'-'-1-1 1
1-'-'-1-1 \
1-'-'-1=1 1
'-'-'-1 I I
1-'-'-1-1 I
1='='=1=1 I
I , , 1 I I
1-'-'-1-1 1
'-'-'-1-\ ,
1-'-'-1-1 1
\-,-,-\-, I
'-'-'-1-\ 1
'-'-'-1-1 ,
1-'-'-1-1 1
\-'-'-'-1 I
'-'-'-1-1 I
'-'-'-1-1 1
1-'-'-1-1 I
,-,-,-,=, I
,-'-'-1 1 I
1='='=1=1 I
I , , I I 1
1='='=1=1 I
1_'_'_1_1 ,
, , 'I_I 1
1-'-'-1 1 I
,-,-,-,-, I
1='='=1=1 1
L BJ-GC-2A (Rev. 3/06)
Attach additional sheet if necessary.
Page 2 of2
I
I
GC-5
--,
NYS RACING & WAGERING BOARD
] Broadway Center, Suite 600
Schenectady, NY ]2305-2553
Telephone (5]8) 395-5400 Fax (5]8) 347-1469
www.racing.state.ny.us
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
GC - ru - ~- [ili]2J - [ilili]iliJ
N.Y.S. Identification Number
This License Must Be
Conspicuously Displayed
During Conduct of Garnes
$1 25.00 II
Amount of Fee Paid Lessor's License Number
Municipal License Number
The following organization:
Address: 1195 Rlliute 376 City: Wappingers Falls, NY
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth, Educational
Names of Members in Charge
Dana Mills
Zip Code: 12590
Joan Mills
Pam Kultsar
Rich Desruisseaur
LICENSE PERIOD
DATE
2007
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
EACH GAME (Starting Bank)
EACH WHEEL
NUMBER OF GAMES
NUMBER OF WHEELS
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
ST ATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
Town of Wappinger
(Name of Municipality)
Town Clerk
(Title of Authorized Officer)
.1
(Date)
e of Authorized Officer)
11111111111111111111111111111 .J ·
1/9/07
L BJ-GC-5 (Re\'. 3/06)