The 4065 Club
..
TOWN OF WAPPINGER
TOWN CLER K
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
May 05,2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$62.72 made payable to the D. C.
Finance Commissioner from The 4065 Club Inc. located in the Town of
Wappinger.
This check covers the additional License Fee for Games of Chance activity
that took place on 04/15/2005.
./~o
/
Glori.'. orse
Town Clerk
smk
Ene.
4130
THE 4065 CLUB, INC.
P.O. BOX 514, ROUTE 82
HOPEWELL JUNCTION, NY 1
1-1288-260
I"
GC-'
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
INSTRUCTIONS: Prepare report in triplicate. Within 7 davs after each license period, send original to clerk of municipality, send one copy to
N.Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, 1 Watervliet Ave. Ext., Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERATIONS
(Please Print or Type)
I
Name of Organization
~ )$;+- _A1("
treet Address Munici ali
Address Where Games are Conducted, if Different:
~i
County
Zip County
[ill] / UJI] / [illJ J - IItM
Date of License Period Hours of License Period
Number of Players
A. RECEIPTS-
1. Admissions (if fee is charged)... .......................................................................... $
2. Profit or Loss from games other than Merchandise Wheels................................ $
3. ~;~: ~~~~ ~~r: ~e~~~;f~::d::;~t~~h~d)................................................. $
4. Total Receipts (Add Items 1,2 and 3)................................................................ $
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
1. Rent
$
~lti\S $
-tL$
---=tl.L<L- $
~$
~$
T~~~
~"-o~ - ~\
f(,. wti\ ()
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d- 0 . [QIQ]
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11111111111111111111111111111 --.J
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ount
:: :::;:=::~~'~~~~:'~:~'~';~:;';:=~;.'~:.':'~::.':~::~:.'~:.'~:::~::~:::~:. ~~: 6:13j
(Include interest bearing accounts)
F. Reconciliation of Unexpended Balance (To be Completed Monthly - - Upon receipt of Monthly Bank Statement)
Depository . Name of Bank Account No. Reconci~ed Balance
1) Checking '^J~~~ ~oaiQJ.q')Y6) I~
2)
3)
Savings
O~ ITTI1JJI9Iill
Total (Must be the same as Line E8 - Unexpended Balance)............................... $ q !. ~
Instructions: This section must be fully completed by all parties.
I swear, or affirm that the information and statements contained herein have been examined by me and to the best o( my
knowledge and belief are true, correct and complete.
E- f:-
First Name
J~O" &x ~8 ~ptwtil sJ- ~~X>)
Street Address City Zip
Ph\J~lSl) ~ - ~ :iA~~Ii~-
Member in Charge:
[ W ~ti
Last Name
~e~ddre~\i S~/\J~ ~ ~ ~'"JUI Juf- Zipl~13
PhLlrlbeylS'l) ~ - CillILIQ] ~;iL~4~L
Preparer (if different):
vO
~
County
10 Irl / @JI] /.[illJ
Date
~u
County I
I al~1 / 10 I ~I / 10 I~I
Date
First Name
~~ do~ ~\, 'br~ h( ~~
]~I~I ) @[];]2J - ~ iLA q~-
I BJ-GC.' (Rev. 4/03) . Page 2 of 2
Zip
fa.6O 1.
coun~
[gill / m- / [QE
Date '
111111111I111111111111111111 -.J
r
GC-7B
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
Organization:
cth ~t-~
Type of Game
No.1 ~~. 1'M-k
Type of Game l _ 0
No.2~b~~
Number of
Locations -L
Number of
Locations b
Starting
Bank 100
Starting
Bank 'J-O
- o,{9~ Date of License Period: (!) / CL:lliJ / [Q1j1
CONTROL SUMMARY
PROFIT OR (LOSS)
(A) -
Game No. 1
CASH CONTROL REPORT
GAMES OF CHANCE
J.D. No.~ -211 - 60\
Type of Game
No.3
Type of Game
No.4
Type of Game
No.5
Number of
Locations
Starting
Bank
Ending ~ Ending
Bank_l/l~ Bank (~'J..,.
~m ~m ~m ~m ~m
(Loss)'& 11.../ 1.( (Loss) I ( d- (Loss) (Loss) (Loss)
-c;::r- (B) (C) (D) (E)
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
WORKERS
WORKERS
Number of
Locations
Number of
Locations
Starting
Bank
Starting
Bank
Ending
Bank
Ending
Bank
WORKERS
WORKERS
v\ L Mt1'"
R- hO(~~
p- 0'
B~
E-.~cl
S ~ (~('JO
(Q.
, bf.-Ai\ Co
\.. -v.\~O
w~ \~
L BJ-GC-7B (Rev. 4/03)
Page 10f2
Ending
Bank
WORKERS
(B) -
Game No.2
(C) -
Game No.3
(D) -
Game No.4
(E) -
Game No. 5
Net Profit
or (Loss)
"I
uD
('lIS. -
/ I), ~
I~J.).. ~
(Enter on Line A-2 of GC-7)
/<9~
~llilllll ml mlllllll ..J
r
MERCHANDISE WHEELS
I
Merchandise Wheel No.1 Merchandise Wheel No.5 Merchandise Wheel No.9 CONTROL SUMMARY
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) PROFIT OR (LOSS)
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. A warded (A) - Mdse.
Wheel No. 1
Profit or (Loss) Profit or (Loss) Profit or (Loss) (B) - Mdse.
(A) (E) (1) Wheel No.2
(C) - Mdse.
Wheel No.3
Merchandise Wheel No.2 Merchandise Wheel No.6 Merchandise Wheel No. 10 (D) - Mdse.
Wheel No.4
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) (E) - Mdse.
Wheel No.5
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. A warded (F) - Mdse.
Wheel No.6
Profit or (Loss) (B) Profit or (Loss) (F) Profit or (Loss) (1) (G) - Mdse.
Wheel No.7
(H) - Mdse.
Merchandise Wheel No.3 Merchandise Wheel No. 7 Merchandise Wheel No. 11 Wheel No.8
(I) - Mdse.
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Wheel No.9
(1) - Mdse.
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Wheel No. 10
(K) - Mdse.
Profit or (Loss) Profit or (Loss) Profit or (Loss) Wheel No. 11
(C) (G) (K)
(L) - Mdse.
Wheel No. 12
Merchandise Wheel No.4 Merchandise Wheel No.8 Merchandise Wheel No. 12
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Net Profit
or (Loss)
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (Enter on Line A-3 of GC-7)
Profifoi-u{Loss)... Profit or (Loss) Profit or (Loss) --.
(D) (H) (L) .'
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
-. L BJ.GC.7B (Rev. 4/03) Page 2 of 2
111111I1111111111111111111111' ~
r MERCHANDISE WHEELS I
I
Merchandise Wheel No.1 Merchandise Wheel No.5 Merchandise Wheel No.9 CONTROLSJ vfl \;rARY
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) PROFIT OR II101s)
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (A) - Mdse.
Wheel No. 1
Profit or (Loss) Profit or (Loss) Profit or (Loss) (B) - Mdse. I I
(A) (E) en Wheel No.2
(C) - Mdse. I
Wheel No.3
Merchandise Wheel No.2 Merchandise Wheel No.6 Merchandise Wheel No. 10 (D) - Mdse.
Wheel No.4
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) (E) - Mdse. I
Wheel No.5
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (F) - Mdse.
Wheel No.6
Profit or (Loss) (B) Profit or (Loss) (F) Profit or (Loss) (1) (G) - Mdse.
Wheel No.7
(H) - Mdse.
Merchandise Wheel No.3 Merchandise Wheel No.7 Merchandise Wheel No. 11 Wheel No.8
(1) - Mdse. I
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Wheel No.9 I
(J) - Mdse. I
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Wheel No. 10
I I
(K) - Mdse. I
Profit or (Loss) Profit or (Loss) Profit or (Loss) Wheel No. 11
(C) (G) (K)
(L) - Mdse.
Wheel No. 12
Merchandise Wheel No.4 Merchandise Wheel No.8 Merchandise Wheel No. 12
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Net Profit
or (Loss) I
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (Enteron Line A-3 Ie ( C-7)
Profit or (Loss) (D) Profit or (Loss) (H) Profit or (Loss) (L)
,
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
-. L 8J.GC-78 (Rev. 4/03) Page 2 of 2
I
11111111111111I1111111111111 ~
r
GC-7B
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
--,
CASH CONTROL REPORT
GAMESOF CHANCE
(,
Number of
Locations
- Otl9a... Date of License Period: 0 / eLm: / [Qljj
CONTROL SUMMARY
PROFIT OR (LOSS)
(A) -
Game No.1
Type of Game
No.5
Organization:
dvh ~t-~
1.D. No.~ - A -60\
Number of
Locations
Type of Gamel. n
No.2~b~~
Number of
Locations -L
Type of Game
No.3
Type of Game
No.4
Type of Game
No.1 ~~ '1' ~k
Starting Starting Starting Starting Starting
Bank 100 Bank J.-O Bank Bank Bank
Ending <": Ending Ending Ending Ending
Bank_tl'~ Bank (j.~ Bank Bank Bank
Profit or .l l '..(' Profit or Profit or Profit or Profit or
(Loss) --L::t:.W-- (Loss) It d-- (Loss) (Loss) (Loss)
(A) (B) (<:) (D) ~)
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
WORKERS WORKERS WORKERS WORKERS WORKERS
(B) -
Game No.2
uO
('f IS- -
I J~ i ~
Number of
Locations
Number of
Locations
(<:) -
Game No.3
(D) -
Game No.4
~)-
Game No.5
Net Profit (SJ-)- ~
G,A\~~ l~ B~ or (Loss)
t>.& 2.r ~-~d ~nter on Line A-2 of G<:-7)
T.. ~(L: S~ (MrJo
,^G ~'" \60
R - hartrl ~ w~ \~
p- 0 I ~m1~i1mnl
L BJ-GC-7B (Rev. 4/03) Page 10f2 --1
TOWN OF WAPPINGER
TOWN CLER K
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
May 05,2005
Dutchess County Commissioner of Finance
22 Market Street
Poughkeepsie, New York 12601
Subject: ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of$62.72 made payable to the D. C.
Finance Commissioner from The 4065 Club Inc. located in the Town of
Wappinger.
This check covers the additional License Fee for Games of Chance activity
that took place on 04/15/2005.
smk
Ene.
THE 4065 CLUB, INC.
P.O. BOX 514, ROUTE 82
HOPEWELL JUNCTION, NY 12533
4130
1.1288.260
I
GC.5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCEl't
BELL JAR 0
RAFFLE 0
GC - [!Ii] -liliGJ- [ili@ - ~
N.Y.S. Identification Number
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
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25.00 II I
Amount of Fee Paid Lessor's License Number
Address: 339 Route 82 City: Wa1>1>inl!'ers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth, Educational
Names of Members in Charge
Peter J. Cassidy
Floyd Scholz
Walter Wych
Michael Perry
LICENSE PERIOD
DATE
Zip Code: 12590
. DAY OF WEEK
HOURS
TYPE(S) OF GAMES
Black Jack
Roulette
Big Six Wheel
Joker Poker - h di P'
AMOUNT OF RAFFLE PRIZES \C-as~ ofMerc an se nzes
at FlUr Market Value)
April 15, 2005
Friday
7:00 pm - 1:00 am
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
2 $ 400.
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
2 $ 100 .
NUMBER OF WHEELS EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
,~",,,,
orized Officer)
11111111111111I11111111111111 ~
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
March 30, 2005
(Date)
L BJ.GC.5 (Rev. 4/03)
..
"
r
GC.S
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE)t
BELL JAR 0
RAFFLE 0
GC - [ili] - ~- [tliI!J - G:ILILGGJ
N.Y.S. Identification Number
NYS RACING & WAGERING BOARD
1 Watervliet Ave, Ex!., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
This License Must Be
Conspicuously Displayed
During Conduct of Games
$/ 25.00 II I
Amount of Fee Paid Lessor's License Number
Address: 339 Route 82 City: Wappinl!ers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity. Patriotic. Youth. Educational
N ames of Members in Charge
Peter J. Cassidy
Floyd Scholz
Walter Wych
Michael Perry
LICENSE PERIOD
DATE
Zip Code:
12590
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
Black Jack
Roulette
Big Six Wheel
Joker Poke.... h di P'
AMOUNT OF RAFFLE PRIZES lC-as~ ofMerc an se nzes
at FaIr Market Value)
April 15. 2005
Friday
7:00 pm - 1:00 am
RAFH..E DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
NUMBER OF GAMES
EACH GAME (Starting Bank)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
2 $ 100.
NUMBER OF WHEELS EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
2 $ 400.
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
-"
orized Officer)
11111111111111111111111111111 ..J
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
March 30. 2005
(Date)
L BJ-GC-5 (Rev. 4/03)
\:
r
GC-4
NYS RACING & WAGERING BOARD
] Watervliet Ave. Ext., Suite 2
Albany, NY ] 2206-] 668
Telephone (5]8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - [!G] - GIiliJ - [!G[lJ - GI1LLLJ
N.Y.S. Identification Number
Town of Wapping-er Dutchess
Name of Municipality
339 Route 82. Wappingers Falls. NY 12590
Address
After investigation, and a hearing if required under Sec. 1920 . al Municipal Law, the following findings and detenninations
have been made:
1. All the members-in-charge designated in the
character and have never been convicted 0
Signature of Person Conducting Investiga' n
es of chance are of good moral
Title S h ~A- \ f+
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)
n/a
ufyes
DNo
[~f Yes DNo
l!f Yes DNa
Ii Yes DNa
ri Y es DNo
I1f Yes DNa
mYes DNa
li Yes DNa
li Yes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result of the findings and detenninations stated above, license is GRANTED [!1'; license is DENIED 0
. f D
SIgnature 0
Filing date of Application March 9, 2005 Authorized Officer
.:J;jph.5'
I I
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-GC-4 (Rev. 4/03) 1111111111111111111111111111\ .J
Date
Title
:..
I
. GC-2B
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
-,
APPLICATION FOR GAMES OF
CHANCE LICENSE
GC-D1]- ~- ~-ICJI71/Ifl;z1
NYS Identification Number
[D/[D/OJ
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR. GAMES)
DATE HOURS RENT
. fJ. ':I / A/ .D. s:~ . . }.:. tJ () oam~- . I.:. o. () (iifiV pm $. /1~f.-.
. /. ./ I am / pm - am / pm $.
. . . . . . . . . . . .
. / . . / . am / pm - am / pm $.
. . . . . . . . . . .
. /. . / . am / pm - am / pm $.
. . . 0 . . . . ,.,
0/ . . / . am / pm - am / pm $.
. . . 0 . . . . . . .
. /. . /. am / pm - am / pm $.
. . . 0 . . . . . . . .
./ . / . am / pm - am / pm $.
. . . . . . . . . ,-,
. / . . / . am / pm - am / pm $.
. . . . . . . . . . .
./ . / . am / pm - am / pm $.
. . . . 0 . . . . . . .
./ . / . .am / pm - am / pm $.
. .. . . . . . ,-,
0/ . . / . am / pm - am / pm $.
.. . 0 . . . . . . .
. / . . /. am / pm - am / pm $.
. . . . . . . . ,-,
RAFFLES PRIZES (Cash or Fair Market
DATE TIME
I Value of Merchandise)
/ ./ am / pm - am / pm 1$. . . . . .-. .
.1 . . . . . . . . .
./ ./ I am / pm - am / pm !$.
. . I . . . . . . . . . . . .
./ ./ I am / pm - am / pm !$.
. I . . . . . . . . . ...
./ . /. I am / pm - am / pm !$.
. I . . . . . . . . . ...
./ ./ I am /pm - am / pm !$.
. I . I. . 0 . . . . . . .
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 STATE ZIP
/1 i~..~I,K~..../~,f' I;',,'rl,~~p /.?tf.'IlfI/
/I&lvnf.'S '~5 Ji,. ""'f' iVY
/ , , ,/
{ )~",.~o C /.""c,,.;,.,... (cJ di/ ~2s1l
,/ , );zY~
v V/ 5r J1,~.J Jt/ #.,
1':-.9 t" /_' '71t:>..!- S U/ J{ --c #71~r./ ti S ,;>.1 tv.:.J/ ffi'f-
/ ' ,
L BJ-GC-2B (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 .J
I SCHEDULE 7 TYPES OF GAMES I
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Vel!as Nil!hts and Bazaars only: The total amount of prizes during anyone license perioctl shall not
aggregate more than $400 for each single type of game of chance when five types of games of chanc~ are to be
conducted during anyone license period. The total amount of prizes during anyone license period sl)all not
aggregate more than $500 for each single type of games of chance when less than five single types o~ games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
tJJ~d /{ )' w ( /<,
/1
I"&",./r J/~
Iii:; .f;"'y w),~p/
at
$ 7't- CJ -
$ YC'i) -
$ /OV -
$ / L'O
$
at
at
j/,) i~~ J'"
Yb/5't'P'
at
at
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
/?//'f
THE TOTAL AMOUNT OF PRIZES FPR
EACH MERCHANDISE WHEEL SHAiLL
NOT EXCEED $10,000 AND NO SING\LE
PRIZE SHALL EXCEED $250
BELL JAR:
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE P~IZE
SHALL EXCEED $500
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YESO NO ~
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO ~
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES ~OR
ALL THE RAFFLES CONDUCTED ~UR-
ING THIS CALENDAR YEAR SHIALL
NOT EXCEED $100,000. NO SINPLE
PRIZE SHALL EXCEED $5Q,000
EXCEPT THAT A SINGLEPRIZaOF
$100,000 MAY BE AWARDED IF' SO
INDICATED IN SCHEDULE 5
L BJ.GC.2B (Rev. 4/03)
Page 2 of2
11111111/11111111111111111111 -.J
I
GC-2A
I
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
GC- rn - ~ - [iliJL] - ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
f'ri'ft.th-d I tel. r J" CClJ5i"&J7 1-L11-1 tr I/o 4,,;;. ,) j hbr"~...11 Yd 1 /;J..rv
7tP~dfA,.er 1 Flo",'" .4 )(I.o/Z. I~I -1L-I 5,).. I ,;2)(101/0'-#/11 l?r fi,"'~A'W'f".....J'4"'1 J2.6t..j'
5t:nt!/c..,Y 1/~i(J Tc'(6feICi'7 D 1.2:-1 ~tJ 1 [LJ~?? S ("c.r;- lie! I h~jL)f,'I! 1 I,zPY
/J''-rec.lur I "'///[&.... A ;/w."f .1,. 1.!.!!..-I..rilLI ~..1 1 /()7 :r4d~~D,. jj 1 F;-.JI.I~;'/I I J.2S:;;Y
rJ"tl!<.n,r I )f,'ct,.&r..! f:.uv 1....2-1 ,;2(, 1..2:1-1 /~9 s 1b,.1"IA"~ X'<<I ~~~6,..,,,'1"l-"'/~ I /~ryC
17,'t'i!1 f"rl U/"J~ltI- J w..,,;" 1--2-I...L-I li-1/9J tl/-1~/~/6,.t1';'" I J!.,/P'UKI/ 1d I /.2$Lf
I/'itl!dol I fbl... t.,,~'n.J I-L-I .r2l?-1 ..t.L 1 J'7 E//z..kj4 t:Jr I (/c.1'...~,...// r,/ I/.,J.Y:?-Y
I ~ 1_1_/_1 I 1
I 1_1_/_1 I I
I 1_1_/_1 I 1
1 1_1_/_1 I 1
Attach additional sheet if necessary.
[ili]/[ili]/~
Date
i.. ., I
:..,~.,.
1',t~V
,
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
OF BIRTH :MEMBERSHIP STREET ADDRESS CITY ZIP
I-!LI -1-1 '5-1 .;)0 I j/ "'1"1.1,0.-.-./ //~ct" )l:y",u.t'I/ J',/ I /;Js-lj
I----L- 1 ~ 1 2Z-1 ;'$-- '';>$' C'/lJuo>r r/i'J/ J:/ r 1 P'O'4 ,..N....."P'S',~I 1'>t.~J
I-L 1 -1- 1 5Y I 13' 1 Jf I oJ~ 5.>- ),,'t:~ hfir A"vl IA-;;"~'''I/ rei 1 J.J. .r~f
1 -# / ....H> / '?;;z 1...:8- 1 /() T J we-/C"'..' 5 I' '-}:;') J./(, 1/ ,} j. j~ "
1 9 1 ,'((, 1531 I~ I/tf~h""u:.n.!i/V .RJI 1.l~C/,~Q..ev/;/<..I/.t:5~
I 1 1 I I 1 I I
1=/=/=1 1 I I
, 1 1 1 I I I
1=1=1=' 1 I I
SCHEDULE 2:
NAME
~/# r ,J" (' u.JJ','d ~
,
fit; ~ eI
,
(..vc. lit,..
,j,l,eJz
W}oC ~
,
"J ...
, ..,~,'
I11/CNAEt..
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2AUXll..IARIES/AFFD...IATES. EACH AUXll..IARY/AFFll..IATELlSTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY/AFFILIATE
GAMES OF CHANCE ill NUMBER
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 -.J
r 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 musjt be a
member of applicant orp;anization or affiliate for at least 1 year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I 1 1 I_I
1-1-1- I _ I
1- 1- 1- I 5'eje' //l/cchee-I'
,-1-1-1=1
1-1-1-1_1
1=1=1= I _ I
1 1 1 I_I
1=1=1= I _ 1
I 1 1 I_I
1-1-1-'_1
1-1-1-'_1
\-1-1-1_1
1=1=1= 1 _ I
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
I 1 1 I I
1=1=1= I = 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_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_1_1_1
1_1_1_1_1
1_1_1_1_1
L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of2
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CITY ZIP
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11111/11111 11/11111111111111 -1
t.-OO i J<.e ,. .>
Name Address City State Zip Code Phone # Birthday Years
in Club
Gerald N. Albanese 52 Hemlock Dr Hopewell Jet NY 12533-5317 227 -3658 24-May-55 6
Denis Beyer 21 Pinebrook Loop Hopewell Jct NY 12533-6200 226-6784 07 -May-52 25
Thomas Bowe 151 Andrews Rd Lagrangeville NY 12540 223-5067 15-Apr -51 21
Thomas J. Brugar 8 Memory Lane Hopewell Jet NY 12533 221-2840 18-Sep-42 1
Peter J. Cassidy PGK Po Box 29 Hopewell Jet NY 12533-0029 226-4526 09-Apr-65 21
Philip E. DeGrandis 2 DeGasperi Rd Wappingers Falls NY 12590 226-4715 29-Mar-44 2
John Fodera 55 Salem Rd Fishkill NY 12524-1030 897 -4481 05-Jan-65 21
David J. Garvey 80 Scott Dr Wappingers Falls NY 12590 297-3046 26-Sep-46 2
Lewis J. Hakim 28 Queen Anne Lane Wappingers Falls NY 12590-6015 226-4150 27 -Jul-45 <1
William Hunt 109 Jackson St Fishkill NY 12524-1117 896-6187 20-0ct-42 25
Deacon Martin C. Kazimir 21 Kipp Ave Fishkill NY 12524 897-5312 19-Aug-45 1
Angelo LaVecchia 93 Mey Crescent Rd Stormville NY 12582 878-9031 09-Aug-47 1
Victor Lyman 30 Bell Air Lane Wappingers Falls NY 12590 296-1137 13-May-60 12
Raul A. Morales 5902 Chelsea Cove Dr N Hopewell Jct NY 12533-7110 227-0323 18-Sep-35 19
Patrick 0.0 Keefe 2 Midge Drive Wappingers Falls NY 12590 896-1708 19-Mar-42 <1
Mario J. Perciavalle 405 Lee Town Rd. Stormville NY 12582 226-3415 22-Dec-60 3
Anthony P. Perrotta 7 Joann Rd. Hopewell Jct NY 12533 227-7932 25-Mar-55 1
John F. Pomarico PGK 35 Mead Ave. Beacon NY 12508 831-4446 24-Jul-67 13
John A. Rotunno 118 Augusta Drive Hopewell Jet NY 12533 226-4978 13-Apr-59 1
James J. Rusciano 1 Blue Jay Blvd Hopewell Jct NY 12533 227-4359 05-Sep-60 2
Floyd Scholz 25 Clover Hill Dr. Poughkeepsie NY 12603-3201 462-0496 06-Aug-52 19
Thomas J. Serraino 56 Elk Rd Hopewell Jct NY 12533 226-8326 11-Nov-63 1
Paul C. Tasetano 338 Cary Rd. Fishkill NY 12524 896-7767 20-Feb-54 2
Walter J. Wych PGK 193 Old Sylvan Lake Rd. Hopewell Jct NY 12533-5402 227-6810 03-Sep-54 13
James Broughton 19 Penns Fishkill NY 12524 8/18/39 10
Bob Bagarozzi 223 Martin Road LaGrangeville NY 12540 11/21/50 1
Frank Fell 3E Fishkill Glen Fishkill NY 12524 3/28/31 3
David Yanolatos 11 Martin Road Hopewell Jct NY 12533 8/7/79 1
Nicholas Longo 6 Namoth Road Wappinger Falls NY 12590 12/27/36 10
Don Hood 705 Chelsea Cove Hopewell Jct NY 12533 9/19/60 4
Bill Carey 17 Park Hill Dr Hopewell Jct NY 12533 12/25/49 2
Craig Grusecki 64 Susan Dr Poughquag NY 12570 5/27/60 10
Ed Mead 41 Flintrock Rd Fishkill NY 12524 3/26/50 3
Santo Armeno 80 Scott Dr Wappinger Falls NY 12590 5/12/35 4
;;~
Thomas Guido
William Scampoli
2 Primrose Lane
162 White Pond RD
Stormville
Stormvlle
NY
NY
12582
12582
10/27/60
12/3/73
1
1
I
GC-2
-,
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
APPLICATION FOR:
PLEASE CHECK
GAMlliSOFCHANCE~
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 A5,~.E-
Fees Received
[ill] I [ill] I rn
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPffiS WITH MUNICIPALITY
GC - [L]I]- ~- [ilQUJ- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
7t'J 1..0""1 ()..f WC,//,'h.9'U- t?l.Al-c L. ~ J J
Name of Municipality County
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes ~ No If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation I;,f
State incorporated /1/ Y .J
Incorporated Association 0
Unincorporated Association 0
State incorporated
DateDJ/D/[BB
DateDJ/D/D
Individual
o
5. Did your corporate status change since your identification number was assigned? 0 Yes IANo
6. Are you doing business under a trade name? 0 Yes ~No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. .?.1 7 A'o ...d~
~~
tv 'l /"~ ~r h,/ b
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? )fI Yes 0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? ~ Yes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes
cJ. 5" 0
/770
o No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
~Yes ONo
If "yes", state the type of licepse and number..
0'1 P ;-"",,'S~..s /,-~ ~f) r . 1 '-'t'4S e
~ tJ () J -2 0 l.#tc.. 0 ~ S- / O~~;)..
13. Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? 0 Y es ~ No
L BJ-GC-2 (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 .-J
r
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
Ct,bl'il~ It'Ct.J"I,~",..ji'L )/rJ"'IJ, Fd,,'-c::.I'~~4/
, J' }
-,
I 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. i .
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 parnes of
Chance Licensing Law and the Rules and Regulations of the Board.
I
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 bt held,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & W_gering
Board and 10ca1licensing 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 of thj: 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 ~rovisions
of local licensing ordinances or laws. I
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended. the Rules and Re~lations
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 i
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Bolu-d.
~/0Il/0] I&~~
Date Signature ~f Head of Organization
STATE OF NEW YORK
~t./lr
Print Name
r La .$$'-7
COUNTY
OF
/)ttfCfI,ESS
ILJ It f fJ I N b- ~ ,€..)
}ss
~OWN/VR.LAGE
OF
. being duly sworn deposes and says that (s)he is the person above nam~d,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has persoQally
affixed his (her) signature to this affidavit. .
Sworn to before me this
day of
,20
Signed
Commissioner of Deeds
Notary Public
My Commission expires
,20
L BJ-GC-2 (Rev. 4/03)
Page 2 of2
1111111I1111111111I111111111 -.J
TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
ROBERT L. VAlDATI
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
March 10, 2005
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, New York 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the "Members in Charge" of "The 4065 Club
Inc.", located in the Town of Wappinger, who will be conducting a Vegas
Night on Aplil 8, 2005.
/I,lJeit:. /5 ~
I would appreciate your review of the application. Please complete the
"Findings and Determination" form attached and return the form to our
office.
Thank you for your attention to this request and your prompt reply.
Yours truly,
-~~/f~~-
Gloria J. Morse
Town Clerk
r~
jS-J4 fI ~ '
10
~~~
I
, GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
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 .
~ame of Organizatioo - - . . . . . -'
GC-[L]]- [WE- ~-~
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 incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
f,,, rei," f I ft" r .r {'. "''''7 I-LI L I t r I /0 be, ,?? #er"",JI Yd I pn.J
.Tte.,~"'r I fl.;,.., N S'~D/7- I~I LI .0- I -"Chv"HHI t?r fi';'<)""FJ~1 12~.J
5,<><1.'7 I 1b.1 T..v'.J~ DILl ';0 I uJ.F~ ur; If,! I ~"JJ,)f.~1 I J,2py
i2' '" 1-0 r IIN,'/Ih ~ '" JA-f J r I ~ I .i'.!L I ..... I /P T 7..,/),... Ji I F,; i XIII 1 P ~ 'T
,1,." " n' r 1 tL ,ch..1 <"" r y I ~ I .;z 6 I.LL lIt T s fi, I,..... r J<'"r 1 k 6,.., ,~,'/", I / ,2s-YD
p,',,, + . r1 t.., Ilor j U/y". I hI L I 12J J9J ,,;.15.1.... M;. ;"r I /Iv,."",,/ " t: I V- ,U
t1,.. d. r I}" i. _ t ""'~ - LJ_j 2?-1 nJ ,17 EI.:,.M4 19,. I ~"'~'r// r,/ I /.)'>7-"
I ' I 1 1 I I ' I
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Attach additional sheet if necessary.
I
loJJI/0EJ/~
Date
NAME
f~f't r J C ~J.J/&I....
,
fi,. l-' eI 5, !'c/ z
,
tve ;It ,- Wire"
,
U/I!,'r<-..,. /1",..1'
J11/~1f' r'e~j!.V
MEMBERSINCH.ARGE OF~GANlES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
OF BIRTH MEMBERSHIP S1REET ADDRESS CITY
I-'LI J-I irl JD I 5"/ ,.,,'.-" I'!.r~ hb/.~,/IJ,J I
I..-i:- I ~ I 5"' 1 .? IT I ~~. rid< "r ;-/,'/1 P r I 1""... ',4'",d ,,.1
12-1 3-1 2L.1 /.7 I IT$ Dj,l ~>/k. t<.~ .....,,1 I~~'W// r-d I
I /0 /;zo 1 '7;1. I ,)3 I /09 jUGj(",~. 5f I h'SJ.,K/I! I
1 ? 1 ~" 1 53 I /~ I A.AL~ ~. I J{f~~#"lev,.f~ I
1_/_/_1 I II
1_/_/_1 I \ I
1_/_/_1 I I \
1_/_/_1 I I I
ZIP
I"JS-V
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)~J? Y
/-.1 ,j ~ tJ
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXn..lARIES/ AFFILlA TES. EACH AUXll...lARY/AFFILlATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFJllA TE
GAMES OF CHANCE ID NUMBER
\1\ 1\\1 \ \1\1 \\11\ \\11\1\ 11\ 1\ ~
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
r'
. GC-2A
I
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
APPLICATION FOR GAMES OF CHANCE LICENSE
TJ, tip t 5
Name of Organization
GC- [ill] - [W]lJ - ~ - ~
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 incorporated or unincorporated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
frf'f:'di''l f I f.ej'f r- S (qJ$I~~ I-LI -LI tr I/o be>- .J. 7 ~/""I.:"'II Yd I /,2J-V
ltPc,)lArFr- 1 F/cyJ 1/ 5'(I./)/Z. 1~/..iL-I ,5;1- I "")C/,;tI~l"H/1I l?r fi.,~.it'l't'-,'J',*",I J2L>~]
5~c.n~fc.,,'T I /~.,J TQ.6ftj!~'1 D 1....1:-1 ~/J 1 il-I_??& Cc,,/ fie! I ;:'-:s~)f,'J! I /,,2.-C2y
tJ"red-o:- I u,,'/),.c.... A )/......1 ..f,- I~I ~I $-..1 1 /py :r4C;XS~.. jj I h-.sJ.I->/l1 I J.2S'?Y
J1tr~,-hlr I }"//cJ.,lltd Atrv 1--2-1 .:z6 1 J.:.LI /bY s !l:.,.Ii'V1&.... .)(.,,1 ~~jJ-,.",,~,.""',.11e I /~J-Y~
p.' r- r, f~' 1"1 1#.-, ~/t I" .r w,.,; I. 12- 1 --L- 1 ..t~_-' /9] ,,/"'" ~/~ Ie-hI' /4 I J),/,yW('// T d- I /.2 .sV
I/'/r-edoi ')&1... tly.&JI7J I.....L-I sl.!!....1 .1:L' .) '/ EI/z"'td~ J:?r I )/e;,,"',*-r// r.,'! I /.,)'>7J
I '1_1_1_1 I ' I
I 1_1_1_1 I I
I 1_1_1_1 I I
I 1_1_1_1 I I
[ili]/[ili]/~
Date
Attach additional sheet if necessary.
j=i, ). t:I
..
We, JI't,-
Je l,c/z
Wy~ "
,
oJ i L
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
OF BIRTH MEMBERSHIP S1REET ADDRESS
I-!L 1 ....L- 1 6'.1-1 ~D I 5/ Me t,~.-d I'I~ 'F
1-1::-1 -L-I ~I /b- I ~$- l/~"'i'r 1'1)// P, 1
I-LI -1-..1 Sf?' 1 I.)' I /91 N~ 5'jo;",&~ ~fi,. A"~I
I I ----1.. .
~...!..::..- I .=.......-' ~ I __~ I" ' "'., J Co<..:. -.. J . ' 1
1_1_1_1 1 1
1_1_1_' I I
'_1_1_1 I I
1_1_1_' 1 I
'_1_1_' I I
CITY
ZIP
/;J>-V
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I I~.$?f
I . _ .. "
jII.~ ....
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SCHEDULE 2:
NAME
jl.,l~ r .J (' uJJ/Py
,
JI:..;I''i'u,,/lj~/ I
f"'",.; l)f""""P'$'Ir-1
,
I*-; ",r /tr,.1/ J d
'" _ I,. t: .,'
I. .. I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/ AFFILIATES. EACH AUXILIAR Y/ AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFlllA TE
GAMES OF CHANCE ill NUMBER
11111111111111111111111111111 --.J
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
~
-
"-
llib...l
..
r
GC.4
NYS RACING & WAGERING BOARD
1 Waterv1iet 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 - m - G:ILGJ - [ili[J - GI::LGIiliJ
N.Y.S.ldentification Number
Town of Wappine:er Dutchess
Name of Municipality
Afte< investigation, and a hearing if required unde.- Soo. 192 of the Genern! Municipal Low, the following findings and dele_ons
have been made:
339 Route 82. Wappingers Fans. NY 12590
Address
1. All the members-in-charge designated in the application to conduct games of chance are of good moral
character and have never been convicted of a crime.
Title
DYes 0 No
Signature of Person Conducting Investigation
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 pr~of 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.
n/a
10. Other findings: (Specify)
i
~Yes DNo
!!f Yes DNa
I
~Yes DNo
ri Y es DNo
I
l!I Yes DNo
o Yes DNo
dYes DNo
~Yes DNo
DYes 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 March 9. 2005 Authorized Officer
Title
TOWN CLERK
(Municipal Licensing Authority)
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 (R", 4103) III mllU I In! till II \\I IIU .-J
Date
- u-----r
'-I......... , -...
.).
DUTCHESS COUN SHERIFF'S OFFICE
Pou . Q,~Qw York
urn
To:
Sandra
From:
Debbie
Date:
03/16/05
Subject:
Findings and Determination
Per our conversation yesterday, William Hunt has to be taken off the application
for Games of Chance License. Please see attached for arrest.
Any questions, please contact me at 845-486-3811.
RECEIVED
MAR 1 8 2005
TOWN CLERK
..
,-
~BRES~/WARRANTI Fl-HELP F3-RETURN F4-INTERSYSTEM FS-ADD ARRST/WRNT
. 'SROWSE F7-PAGE BWD Fa-PAGE FWD F9-PROPERTY Fll-CONTACTS
~-------------+ F12-INCIDENTS ENTER-DISPLAY CLEAR-END
SUBJECT: HUNT, WILLIAM R
DATE TIME INCIDENT NO. STATUS/OFFICER COURT
SDLOE023
ARREST 12/08/1993 1:16 93-008241-001 F. LAMONICA
VTL 1192 -02 OPER MV .10 OF 1% ALCOHOL 1ST CL U MIS 0 DEG
VTL 1192 -03 OPER MV WHILE INTOXICATED 1ST CL U MIS 0 DEG
VTL 0375 -02 MV LIGHTS DONT MEET STANDARDS CL 0 INF 0 DEG
VTL 1120 FAILURE TO KEEP TO THE RIGHT CL 0 INF 0 DEG
VTL 1126 DRIVING LEFT OF NO PASSNG ZONE CL 0 INF 0 DEG
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------
024 - NO FURTHER ARRESTS TO DISPLAY
io<<t "'('*
-..,
~ 1J~.5.'
I
r-<
.GC-2
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMESOFCHANCE~
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 I OJ/m/OJ
Fees Received Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - CLIIJ - ru1J- [iliILJ - ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
7tfJ U;".., ~.f W all' "-.rer t?lAl-e t.... oF..s
Name of Municipality County
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes ~ No If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation ~
O State incorporated /// Y 5
Incorporated Association
Date m / m / [ilij
Date m / m / OJ
Unincorporated Association 0
State incorporated
5. Did your corporate status change since your identification number was assigned? 0 Yes ~No
Individual
o
6. Are you doing business under a trade name? 0 Yes ytNo If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. 3 3 7 A'ClJ ~ Ie ~ ,)-
U; &- /' /,,'hJ tf'f- h,/ (;
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? ~ Yes 0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? ll\ Yes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes
J. 5"0
IJ70
o No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
~Yes ONo
If "yes", state the type of liceJlse and number. e
0" fl;-o,,"'S~..$ /f)""r l,-t:.t'"'s
v7 () () 3 ~;l 0 'tIc.. 0 F' )-/O')'5;z..
13. Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? 0 Yes ~ No
L BJ-GC-2 (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 -1
r
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
C t, L:/I" r J ~ ~ Ct.J r- tI-,..J./l') )/n ..1'11, ff C/", LC. -he> '-' 4 /
,} ,
1
'..:'
I 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 answ~s
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 Gllmes 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 ~eld,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wag~ring
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 of the ~icense,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N. Y .S. Racing & Wagering Board and with the pr4visions
of local licensing 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 Regul*ions
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.
[J]/[J]/[[] I~ 1'~
Date Signature (if Head of Organization
~to4?,-
Print Name
:r {' c, .$ $ rv'11
,
STATE
OF
NEW YORK
}ss
COUNTY
OF
CITY rrOWNIVIILAGE
OF
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
day of
,20
Signed
Commissioner of Deeds
Notary Public
My Commission expires
, 20
L BJ-GC-2 (Rev. 4/03)
Page 2 of2
111111111111111111111111" III ..J
r
,GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
Th y/J t ~-.
Name of Organization
GC- [ill] - CW1tJ - [iliIJ - ~
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 incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
f'rH,-df''1 f 1 fd~ r J" ('c,j5'~~ 1.11.1-1 tr I/o ~(})o ,) , I ~rk.41 ..rd- I /;2.rv
JtPQSfArer I No,"eI /I fr/'o;z. 1~/..6--1 5:J.. l.;2rClcvt,.II/11 ~r I ~p"iA"I"t",..s~1 J2~t...3'
5ec..-~fo.~7 I !a "I T.:;6fe!c,'I () I~I ;UJ I il-I_??s C,,~~ ~eI I F,~J/'}f,~1 1 J,2~Y
!J,'-/"er.J.ur- I Un'llltH. A ~#fl .if' I~/.ELI $'.2. 1 /P7 Te,dHD.. jj I J=;-.sl.l~,'/I I J.2S?Y
~I'rt! "Iv r I /1,'ct,.tr d At t"\/ I ~I .:z.6 1....tL I JbJo s 1b~/"V1~~ fi vi ~~J6,..."SI"l-')'/~ I /;).Y'Y~
/Rr-el f clrl Uo.-, (1'0" ,r ~r; I. 1-2-1 ..LI li-1/9J (JIll 5;-1w- Ie-/)" 114 I )j.,/,rWt'/1 7d-1 /.2~5J
I/'het,lo/' I ~ i,... tly'c-'P1f L.LI .td..!!.-I .tL I .) '/ EI/z.,I,,;'1 I!lr- I ~C>iJ"'k,,..//r,/ I /.,)'>"7...1
I '1_1_1_1 I ' I
I 1_/_/_1 I I
1 1_/_/_1 I I
I 1_/_/_1 I I
Attach additional sheet if necessary.
OJ/CD/CD
Date
NAME
i<t-I'fr .J' (".JJ,'dy
,
f/H eI ~c_I,~/z
,
tvo llt,- Wyf. ~
,
u.J'II,'~ "'" ;/<r#':I'
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
, OF BIRTH MEMBERSHIP STREET ADDRESS
1---fL I -L- I '$-1 ..1(.) I j/ Me t,o;-~.; /IQ ~{"
I-L. I -1L- 1.2.Z-1 ;> $- 1;5 S' r'/"mr /-I.'jl t:J r 1
1-2- I -3- I 5Y I /.;' 1 /9 ~ (JJ~ 5." J~" I-<-/f,. ,I(~I
I..LLI .dE-..-I.kL1 ~3 I /07 Jc,(.j(fPo,' Sf I
1_1_/_1 I I
1_1_/_1 1 I
1_1_/_1 I I
1_1_/_1 I I
1_1_/_1 I 1
SCHEDULE 2:
CITY
):1:'1' y u-d I .J' ~ / I
/o'~ 'j("'''.I'",S'',~1
/ft;;"~"1/ lei I
~'"'sh,l{/I/ I
I
I
I
I
I
ZIP
I;J s-V
) ~6P.J
J,). .r~.i'
)..).J~Y
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXll..IARIBSI AFFn..1A TES. EACH AUXll..IAR YI AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXIT..IARY/ AFFILIATE
GAMES OF CHANCE ID NUMBER
1III11111ll111III 111111\ 1111\ .J
L BJ.GC-2A (Rev. 4/03)
Page 1 of2
----,
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 ~Ie a
member of applicant organization or affiliate for at least I year. .
YEARS OF
MEMBER NAME . DATE OF BlRTH MEMBERSHIP STREET ADDRESS
I 1 1 I_I
1=1=1= I _ I ~
I 1 1 I Sef ,I/lfcche-f
'-1-1-'='
1=1=1= I _ I
1_1_1_1_1
1_1_1_1_1
I 1 1 I_I
1-1-1-1_1
'=1=1= I _ I
1_1_1_1 _I
I 1 1 1 I
1=1=1= 1 = I
I 1 1 I_I
1=1=1= I _ 1
I 1 1 I_I
'-1-1-' I
'-1-1-1-1
1=1=1= I = I
1_1_1_1_1
1_1_1_1_1
I 1 1 I_I
1-1-1-' I
1=1_1= 1= 1
I_I_/~ I_I
1_1_1_1_'
I 1 1 I_I
1-1-1-1 1
1=1=1= I = 1
I 1 1 I_I
1=1=1= I _ I
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY ZIP
I
I
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:1
:1
:1
1/111111111111111111111111111 ~
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Vb c:H 1< -e r ->
Name Address City State Zip Code Phone # Birthday Years
in Club
Gerald N. Albanese 52 Hemlock Dr Hopewell Jet NY 12533-5317 227 -3658 24-May-55 6
Denis Beyer 21 Pinebrook Loop Hopewell Jet NY 12533-6200 226-6784 07 -May-52 25
Thomas Bowe 151 Andrews Rd Lagrangeville NY 12540 223-5067 15-Apr -51 21
Thomas J. Brugar 8 Memory Lane Hopewell Jet NY 12533 221-2840 18-Sep-42 1
Peter J. Cassidy PGK Po Box 29 Hopewell Jet NY 12533-0029 226-4526 09-Apr-65 21
Philip E. DeGrandis 2 DeGasperi Rd Wappingers Falls NY 12590 226-4715 29-Mar-44 2
John Fodera 55 Salem Rd Fishkill NY 12524-1030 897-4481 05-Jan-65 21
David J. Garvey 80 Scott Dr Wappingers Falls NY 12590 297-3046 26-Sep-46 2
Lewis J. Hakim 28 Queen Anne Lane Wappingers Falls NY 12590-6015 226-4150 27 -Jul-45 <1
William Hunt 109 Jackson St Fishkill NY 12524-1117 896-6187 20-0ct-42 25
Deacon Martin C. Kazimir 21 Kipp Ave Fishkill NY 12524 897-5312 19-Aug-45 1
Angelo LaVecchia 93 Mey Crescent Rd Stormville NY 12582 878-9031 09-Aug-47 1
Victor Lyman 30 Bell Air Lane Wappingers Falls NY 12590 296-1137 13-May-60 12
Raul A. Morales 5902 Chelsea Cove Dr N Hopewell Jet NY 12533-7110 227-0323 18-Sep-35 19
Patrick D. 0 Keefe 2 Midge Drive Wappingers Falls NY 12590 896-1708 19-Mar-42 <1
Mario J. Perciavalle 405 Lee Town Rd. Stormville NY 12582 226-3415 22-Dec-60 3
Anthony P. Perrotta 7 Joann Rd. Hopewell Jct NY 12533 227-7932 25-Mar-55 1
John F. Pomarico PGK 35 Mead Ave. Beacon NY 12508 831-4446 24-Jul-67 13
John A. Rotunno 118 Augusta Drive Hopewell Jct NY 12533 226-4978 13-Apr-59 1
James J. Rusciano 1 Blue Jay Blvd Hopewell Jct NY 12533 227-4359 05-Sep-60 2
Floyd Scholz 25 Clover Hill Dr. Poughkeepsie NY 12603-3201 462-0496 06-Aug-52 19
Thomas J. Serraino 56 Elk Rd Hopewell Jet NY 12533 226-8326 11-Nov-63 1
Paul C. Tasetano 338 Cary Rd. Fishkill NY 12524 896-7767 20-Feb-54 2
Walter J. Wych PGK 193 Old Sylvan Lake Rd. Hopewell Jct NY 12533-5402 227-6810 03-Sep-54 13
James Broughton 19 Penns Fishkill NY 12524 8/18/39 10
Bob Bagarozzi 223 Martin Road LaGrangeville NY 12540 11/21/50 1
Frank Fell 3E Fishkill Glen Fish kill NY 12524 3/28/31 3
David Yanolatos 11 Martin Road Hopewell Jet NY 12533 8/7/79 1
Nicholas Longo 6 Namoth Road Wappinger Falls NY 12590 12/27/36 10
Don Hood 705 Chelsea Cove Hopewell Jct NY 12533 9/19/60 4
Bill Carey 17 Park Hill Dr Hopewell Jet NY 12533 12/25/49 2
Craig Grusecki 64 Susan Dr Poughquag NY 12570 5/27/60 10
Ed Mead 41 Flintrock Rd Fishkill NY 12524 3/26/50 3
Santo Armeno 80 Scott Dr Wappinger Falls NY 12590 5/12/35 4
.s
Thomas Guido
William Scampoli
2 Primrose Lane
162 White Pond RD
Stormville
Stormvlle
NY
NY
12582
12582
10/27/60
12/3/73
1
1
.'
r
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
It
Name of Organization
m/m/[O
Date
GC- D1J -ldLJ[] - ~-1t!J17IJ Ifl~1
NYS Identification Number
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR. GAMES)
HOURS RENT
. 7.:. LJ () .am@- . . /.:. O.IJ6iftDpm ! $ . 40~/,.,
am / pm - .am/pm ! $.
. . . , . I. . . . .
am/pm - ,am/pm!$ .
I . . . . . . . ,-,
am / pm - .am/pm ! $.
. . , . . . . . ,-,
am/pm - ,am/pm! $ ,
. . . . . . . . . .
am / pm - am / pm !$.
. . I . I . . , . . . ,
am / pm - .am/pm ! $.
. . . , ,- . . -,
am / pm - .am/pm ! $.
I . . , . . . ,-,
am/pm - am / pm !$.
. . . , ,- . , ,-,
am/pm - ,am/pm! $ ,
. . . . . . . I.'
am/pm - ,am/pm! $ ,
I. . . I. . ,-,
am / pm - am / pm !$.
. . . . . . . , I.'
DATE
. tJ. '/. / .0, f. / .0. s:~ .
I
. .
I
. .
I
,
. .
I
,
. .
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,
. .
I
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,
. .
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. .
I
, / .
, / .
. / .
. / .
. /.
. / .
. / .
. / .
. / .
. / .
. /.
DATE
. / .
, / .
, /.
. / .
, /.
, / .
. / ,
,/ .
. / .
, / ,
,/ .
RAFFLES
. .
,- .
am / pm
.
am / pm
,
am / pm
,
am / pm
,
am / pm
,
PRIZES (Cash or Fair Market
Value of Merchandise)
!$. . . . . ,', .
!$.
\$.
!$.
!$.
. . .
TIME
I
, I .
I
. I .
I
. r .
I
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I
am / pm -
,
am / pm -
.
am / pm -
,
am / pm -
,
am / pm -
i
. . .
... .
. / .
. / .
. / .
, / .
./
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
frcll/nrl'S '~5 lJj;4")zK~"'i/~''PJ;,.,,uf' Itv~4~~/p
/ " /
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. . .
, .
. . .
. . .
. . .
. . .
. . .
. . .
. . .
. I .
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.. .
. . .
?J / tv.:.}/ .f I-
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STATE
rvY
,t/Y
A/Y
ZIP
},7M/
!.2sfl
Jp.Y~
L BJ.GC-2B (Rev. 4/03)
Page 1 of2
11111\ I 111\1 \11\\\1 \l\IIIIUI .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.
'J.,
Note for Ve2as Ni2hts and Bazaars only: The total amount of prizes during anyone license period $haII not
aggregate more than $400 for each single type of game of chance when five types of games of chance ?re to be
conducted during anyone license period. The total amount of prizes during anyone license period sh1UI 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)
1.1/.-; I' /{ .r ,-:. c /<,
.
11
/)&!;" /1" J/ ~
;JiJ ..f,""y wkco@/
at
LIST THE MAXIMUM AMOUNT OF PJlUZES
TOBEAWARDEDFOREACHTYP OF
GAME OF CHANCE (GAME BAN .
$
$
$
$
$
7't'o -
y.o iJ -
at
at
/()o
T,.) i~'i' i~
i0)5Y'J!'
at
/vo
at
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
/?//f
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALt
NOT EXCEED $10,000 AND NO SINGL~
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF TIllS APPLICATION
IS FOR A BELL JAR
LICENSE
YESD NO ~
THE TOTAL AMOUNT OF PAYOUtS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PR.$ .
SHALL EXCEED $500
RAFFLES:
L BJ-GC-2B (Rev. 4/03)
Page 2 of2
THE T OT AL AMOUNT OF pRizEs F~
ALL THE RAFFLES CONDUCTED DU -
ING THIS CALENDAR YEAR SH . L
NOT EXCEED $100,000. NO SINGIjE
PRIZE SHALL EXCEED $50,ObO
EXCEPT THAT A SINGLE PRIZE dF
$100,000 MAY BE AWARDED IF ~O
INDICATED IN SCHEDULE 5
1/111111111 111111111111111111 --.J
INDICA TE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESD NO ~
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
,,?(
r:
, GC-2A
-,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
GC- [ill] - ~ - 10101/ 1- [Ql2IJill
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 incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
frf 51r/.,,., f. I ~/: L.L. ;I'IM f(, !lit;.) 7S ~. II.!..-I 2...fLI 'r.2 1/~7 J,., c KS a tJ sfl (~s A. J< ,'( (. .<lA, / ~ s .-.z.'t'
7r(,~1Ur-"r 1 f(oJ~_ At ScholL I-L.I ..iLIS;"'!JSUOvRr( [ill )r, I !6~h~I\?. I (d605
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Attach additional sheet if necessary.
OJ/OJ/[D
Date
NAME
MEMBERS IN CHARGE OF GAl\1ES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DAlE YEARS OF
OF BIRTH MEMBERSHIP STREET ADDRESS
ILl LI 6; I ;20 I 67 C)fC/'Ot.! //t>(~
I JL 1 ..f2- 1 S:A. I ;).f3 IJ-s (j~ Irk II 6r,
I -L 1 .2- 1 ::::L I 13 1 (r J 0..0 .it, v,4,c/tAIC.t 4
I !.5!.- 1 ~ 1 E-I J....J I I CJ ll/(cks "A/ 57
'_1_1_1 I
1_1_1_' I
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1_1_1---1 1
CITY ZIP
I h"~~ fd I /..25'3'3'
I (Jo,-" ;~ /IVY I (J-6o <
1 t/'CJ~-wr? L kr 1 I '2 r JJ
16;s,{t; u..., 1J'v I J;l.S" a?~
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SCHEDULE 2:
fJ.,/pr r ~J(.I.,
,
field S, l,c)/Z
.
tv" /I.. r /,V)ic /..
ty;//;", - 1/(.", j-
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXll.-IARlES/AFFlLlA TES. EACH AUXll.-1AR Y/AFFU...IATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUxn...IAR Y/ AFFIlJA TE
GAMES OF CHANCE ill NUMBER
11111111111111111111111111111 -.J
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
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 mu~t be a
member of applicant or~aniZ8tion or affiliate for at least I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1_1_1_'_1
1_1_1_1 _I
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1-1-1-'_1
1=1=1= I _ I
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1=1=1= I _ I
1_1_1_1 _I
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1_1_1_'_1
1.2-1_1_1_1
'_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_1_1_1
1 1 1 I_I
1=1_1= I_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
1~1_1_1_1
1_1_1_1_1
1_1_1_'_1
'_1_1_1_1
L BJ.GC.2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
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11111111/11111111" 11/11/111/ -.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 GA:MES OF CHANCE
LICENSE
GC -lli] - [2]Lli] - ~ - CclZJLIiliJ
N.Y.S. Identification Number
7 Ow,., (.) f
Name of Municipality
tJl.dc.l,toJ'J
17'9
Address
Fe.. 115
1,2;-<;-0
1r;2..
UU:t~"~ "e l- ()
, ,
A/7
After investigation. and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and detenninations
have been made:
1. AlI the members-in-charge designated in the application to conduct 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 quaijfied 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)
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and detenninations 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 (Rev. 4/03) 1111111]11111111111111 \ 11\11\ ~
~
r.
.GC-S
I
GC - ~ - CllLI$]-
N.Y.S. I~on Number
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR fB1
RAFFLE 0
WQlL]- ~
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.riy.us
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 II I
Amount of Fee Paid Lessor's License Number
Address: JJe; i'n,,!fP b- 2. 10 p()Jt. ~/y City: Ift;/,'wdl f tI-
Entire net proceeds to be devoted to the following specific lawful purpose(s):
c /"Or;/ y, /oft-to ii' c )DIAl;' t:cluc~I,"#<~/
Names of Members in Charge/ / /
It; V! r .r CCl5$,P y
FlOyd 11 Ie I.,p/z.
,
Zip Code: / 2. ~? J'
tv Q J f~ r J 'w Y (" j.,
WN';o,.". ;lu'11
liCENSE PERIOD
DATE DAY OF WEEK
Yr'o r- ;'loD Y
HOURS
TYPE(S) OF GAMES
t!ell r
,cr-
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
al Fwr Markel 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 (Slarting 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
(Title of Authorized Officer)
(Name of Municipality)
(Signature of Authorized Officer)
/1111111111111111111111111111 -'
(Date)
L BJ.GC.S (Rev. 4/03)
r
GC-2B
NYS RACING & WAGERING BOARD
I WatervIiet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453.8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
APPLICA TION FOR GAMES OF
CHANCE LICENSE
GC- rn - [W]i] - [&clJ - GIZILJM
NYS Identification Number
OJ/CD/CD
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR. GAMES)
DATE
. / . , / ,
,/ , , / .
, / " , / ,
, / . . / ,
,/ , ,/
, / . , / .
, / . . / .
. / . ,/ .
, / . , / .
. / , ,/
, / , , / ,
,/. ,/ ,
RAFFLES
DATE
/ . /
. / . / .
. / . / .
. / . /
. / . /
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HOURS
am /pm -
,
am /pm -
,
am /pm -
,
,am / pm -
,am / pm -
am /pm -
,
am /pm -
,
am /pm -
,
am /pm -
,
am / pm -
.
am /pm -
,
am /pm -
,
TIME
am /pm -
,
am /pm -
,
am /pm -
,
am / pm -
,
am / pm -
,
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RENT
,am /pm ! $ .
, am / pm ! $ .
,am/pm!$ ,
,am /pm ! $ .
,am/pm! $ ,
,am/pm!$,
,am/pm!$.
.am/pm!$ .
,am/pm! $ ,
,am/pm! $.
,am/pm! $ ,
,am/pm! $.
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am / pm
.
am / pm
,
am / pm
am / pm
,
am / pm
,
PRIZES (Cash or Fair Market
Value of Merchandise)
!$. , , . , ,'. .
!$.
1$.
!$.
!$.
II .
o' .
,-,
,-,
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
L BJ-GC-2B (Rev. 4/03)
STATE ZIP
Page 1 of 2
1\111111111111111111111111111 ~
r SCHEDULE 7 TYPES OF GAl\1ES -,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve2as Ni2hts and Bazaars only: The total amount of prizes during anyone license perio~ shall not
aggregate more than $400 for each single type of game of chance when five types of games of chanc~ are to be
conducted during anyone license period. The total amount of prizes during anyone license period sijall not
aggregate more than $500 for each single type of games of chance when less than five single types o~ games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
UST THE MAXIMUM AMOUNT OF tRIZES
TO BE AWARDED FOR EACH T~E OF
GAME OF CHANCE (GAME BAliK)
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 FQR
EACH MERCHANDISE WHEEL SHAll
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YES ~NO 0
THE TOTAL AMOUNT OF P A Y01J;TS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 ANI?NO SINGLE PRizE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICA nON
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 F~
ALL THE RAFFLES CONDUCTED D R-
ING THIS CALENDAR YEAR SH
NOT EXCEED $100,000. NO SINdJLE
PRIZE SHALL EXCEED $50,/)00
EXCEPT THAT A SINGLE PRIZE ioF
$100,000 MAY BE AWARDED IF Iso
INDICATED IN SCHEDULE 5
L BJ.GC.2B (Rev. 4/03)
Page 2 of2
111111111111111111111I/1111111 ..J