Wappinger Elks Lodge (3)
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GC-2
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR 0
RAFFLE 0
$\ 25 .00 j
Fees Received
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
FOR OFFICE
USE ONLY
GEJTw/GJL]
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPlES WITH MUNICIPALITY
GC-m-[JJJTI]-~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
'\' oU.nJ D ~ W ~ P ('\ tJ~ ~(.t \) vT c.. \J-tf. ~
Name of Municipality County
2.
3.
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation 0 't
Incorporated Association ~ State incorporated tv fl.LV () ~ \L...
Unincorporated Association 0
State incorporated
Date ~ I LQI1J / ~
Datern / rn / rn
Individual
o
5. Did your corporate status change since your identification l\tl~r was assigned? 0 Yes ~No
6. Are you tloing business under a trade name? 0 Yes ~No If "yes", what is the trade name?
PART B, LOCA TION OF GAMES
7. Address where games, bell jar. or raffle drawing(s) are to be conducted. l t q b ~. ~ l (,
8. Name and address of authorized games of t 1\ I n
chance lessor renting to applicant. f""' LI1
oJ prr p . ~ '\J- t<"
\
9. Does the applicant own the premises? fj( Yes 0 No If "yes", how long'!
I O. Capacity for public assembly of premises presently owned or occupied.
d- 8h
II. Have premises been regularly used? ~es 0 No If "yes", how long? :J.-J.. i ~F\-R.. 7
Are games of chance being played now on these premises or has it ever been?)itYes 0 No If "yes". give full details.
MB'I l,' ~Of)~
12. Are the premises or any part thereof
where games of chance are to be played f:1;/es 0 No
licensed by the State Liquor Authority?
If "yes", slate the type oflicense and number.
CL"OOO /4 d-.Lf ~
13. Has such license ever been
revoked or suspended? 0 Yes
~o
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ.GC.2 (Rev. 4/03)
Page 10f2
11111111111111111I11111111111 .J
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PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner. ,
l i3 ClJfJi~ lTJ}8uz,-. Q-13 OY?Iz-R-~Jl OL~
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I swear (or afImn):
I. That ALL the attached Schedules are a material part hereofand are incorporated herein as jfset 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 primllTily 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 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
oflocal 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 Regulations
of the N. Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no conunission, 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.
~ / ffi] / [gi] s;~~o~
NEW YORK }
OF Vcr-rC-w-a- S ~
W "'f'f' '''1 EL 55
K- 0 ~ eo VA Lt:. 1J IE: 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.
;-e OCc-'O
V~Lf7VT6
Print Name
STATE
OF
COUNTY
CITY nOWNNILLAGE
OF
Sworn to before me this ':;'~i:l day of ~ , 20 ~
SfHu.} -S. Dab6u.is ov-
Notary Public
My Commission expires ~ 3..:> , 20 ~
S;gn~ ~
Commissioner of Deeds
SARA J. DOBBINS
Notary Public, State of New York
Qualified in Dutchess County
Certified in Westchester County
Commission No. 01004865746
Commission Expires Jttfy-tt, J>ld()/~/o
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L BJ-GC-2 (Rev. 3/06)
Page 2 of2
~llll~ IIlml" III ~ --1
Schedule 1: Officers and Directors
;).. Oo~ q ~ ~(C).~ ~
WAPPINGER LODGE #2609 OFFICERS for 2'r- IR9~
Title
Exalted Ruler
Leading Kgn
LoyalKgn
Lect. Kgn
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
Trustee
Trustee
Trustee
Trustee
Trustee
Name
Address
Joseph P. Havelka Sr.
Eileen E. Boyer
Diana Cole
Paul Bader
Mark H. Fox
Catherine Rohling
Rosemarie Perretta
Robert M. Acquanita
Pamela S. Kultsar
Susan Dorler
James Boyer
Rocco Valente
Alex Czarniecki
Alfred DeRose
Vacant
38 Hickory Lane
134 Andrews Road
P.O. Box 549
134 Andrews Road
28 Tiger Road
54 Brothers Road
35 Cathy Road
10 Vorndran Dr.
58 Hillis Terrace
21 Valley Road
134 Andrews Road
61 Fishkill Hook Rd.
31 Helen Drive
25 Hickory Lane
No Officer receives compensation of any kind.
Town
Pawling
Lagrangeville
Hughsonville
Lagrangeville
Hopewell Jct.
Wappinger Falls
Poughkeepsie
Wappinger Falls
Poughkeepsie
Wappinger Falls
Lagrangeville
Hopewell Jct.
Wappinger Falls
Pawling
Zip
12564
12540
12537
12540
12533
12590
12603
12590
12603
12590
12540
12533
12590
12564
DOB
11/13/1942
01102/1943
04/25/1948
09/20/1965
09/15/1957
04/22/1940
08/07/1943
OS/25/1942
02/01/1950
03/29/1939
11/28/1937
06/06/1941
10/16/1941
11/28/1961
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GC-2A
NYS RACING & Vi AGERING BOARD
] Viatervliet 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 UCE...WSE
GG]/w/GJ]
Date
CITY ZIP
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NAlv.rE
M:EMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF .
OF BIRTH MEMBERSHIP STREET ADDRESS
1_1_1_1 I
I 9/ 20 1 1965 I 14 I 134 Anderews Rd
1----; / 16 /-:;;;; I 7 I 9 S. VIeW lJ1
, 7 / -ZL 1 ~l (;) I 28. Q~eeFl }\f1f1fl Ln
I 7 / 01 / 1936/ ?R I 1'4 n::.n::. PlilCP.
1-1=1=1 I
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CITY
ZIP
,CfIEDULE 2:
Simon Kaufman
1
I laGrange
I Hopewell Jet
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12540
12533
12590
12590
Paul Bader .
Lewis Hakim
3reg Sarno
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SCHEDULE 3: AUXILIARY/AFFlLL4LTE ORGANIZ..~TIONS ASSISTING AT GAIv.ffiS
(MAXIMUM OF2 AUXlLIARIESfAFFU-JATES. EACH AU)ill.lARY/AFF!LlATE LISTED MUST HAVE ITS OWN ID NUMBER.)
N.AME OF AUXILIARY IAFFILIATE
Gillv.ffiS OF CHA.NCE ID NUh1BER
\llllllHlllllll\ IlU! 1111111 -1
BJ-GC-2A (Rev. 4/03)
Page 1 of2
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. GC-2A
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NYS RACING & WAGERING BOARD
1 Watervliet Ave. Exl.. Suite 2
Albany. NY 12206-1668
Telephone (518) 453-8460 Fax (5I8) 453-8492
www.racing.state.oy.us
APPLICATION FOR GAMES OF CHANCE LICENSE
[JJ/Q]/GQ
Date
CITY ZlP
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,CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANlZATlON)
DATE YEARS OF
NAME OF BIRTH MElv.ffiERSHIP sTREET ADDRESS CITY ZIP
PaulBader 1_/_1_1 I. I I
I 9/ 20 1 1965 1 14 I 134 Anderews Rd I laGrange I 12540
Simon Kaufman ,---S/-W I~I 7 I 9 S. VIeW In I Hopewell Jet I 12533
Lewis Hakim I 71 -ZL/~I 6 I 18< QYSeA MAe In I YVappiogp-", F::allc:: I 12590
3reg Sarno I 7 I 01 I 19361 28 I 1 ~ n::an<> P'v"" I W<lpping8~ F:IIIE I 12690
1=1=1=1 I I I
1_1_1_1 1 I I
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SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILlARlESlAFFILlA TES. EACH AUXILIARYI AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY! AFFILIATE
GAMES OF CHANCE ill N1Jl\.1BER
\111111111111\111111111111111 --.J
_ BJ-GC-2A (Rev. 4/03)
Page 10f2
SCiu':DULE 4:
ASSlSTAi'lTS TO MEMBERS 1.1"i CHARGE OF GAf\'1ES
Li$1 aii meRlbe~ of appliClUlI orglUlizalion and lllembers of autborizod affiiilltes and auxiii..y who wiii assist with games. Each per.;on iislCd must be n
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YEARS OF
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STTIEET /'.J;DRES~:
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DATE OF BIRTH I\1EI\H3ERSIIIP
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Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jct 11 04/24/1940
Philip A. Abbate 6 Hackensack Hghts Rd Wappingers Falls 18 05/16/1937
Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivina 12 Thorns Lane Highland 22 12/21/1935
Henry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset Hill East Fishkill 18 02123/1936
Francis J. DeGano 27 Brandy Lane Wappingers Falls 18 07/18/1946
Roger DeJordy 83 Kent Road Wappingers Falls 18 09/19/1944
Robert Fischetti 91 Ardmore Drive Wappingers Falls 28 06/07/1926
Mark H. Fox 28 Tiger Road Hopewell Jet. 14 09/15/1957
Harris C. Jones 217 Brothers Road Stormville 18 04/24/1944
Robert J. Juliano 2776 West Main Street Wappingers Falls 13 10/05/1953
William K. Minkowski 427 McGrath Blvd. Fishkill 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wappingers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Kinry Road Poughkeepsie 19 01/17/1933
I
GC - tB
NYS KAClI'-JG S: WAl/ERING BOAHI)
I WUlci"ylicl AYe. Ext., Suitc 2
AJlm!l}, NY 12206- \ 66H
']',kpll\lIlC i518) 453-84()O hll( (SIll) 45.l~WYl
www.ra..;illg.$l<llc.n'j.I.I$
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APPLICATION FOR GAMES OF.
CHANCE LICENSE
*'.1
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GC- [ill- [l[ili] - ~ - ~
NYS ldentificatlon Number
[@/I?-ftil / ~
Date
SCHEDULE 5 DATES, HOl1RS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(,VOl' APPLICABLE FOR BELL JAR GAMES)
HOURS
, : ]}~2.am (fJj)- I Jt QQ ~@m I $ ,
-----'--' . _ ,am / pm _ , . .am / pm i $
,am / pm - . ' ,am / pm ! $ ,
.am / pm - ~..--,' .am / pm I $ ,---,,-. ,
'---"--' .am / pm - ,am / pm ! $
__.__~___.: ~__~___,am / pm - , , ,am / pm 1$, , .
~________ .a m / pill - .a I11 / pm I $ <-----'-____
,---,--, . ,am / pm .. , ' am / pm i $
~_.._..__~: ~.._------,am / pm - ,am / pm i $ I
,am / pm .:' " am / pm i $
"am/pm-,.:. ,', ,am/pm 1$
~ '
~_~ : '----"-'~am / pm ~. ~~.: ._~~ am / pm I $
RENT
DATE ·
oS /!Z11 Q?f
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'-______........ "'--~ ~.J
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I . 10--.___0
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PRIZES (Cash or Fair Mdrk~l
Value of Merchandise)
!$~,
!$,
!$.
!$.
!$
RAFFLES
DATE
TIME
~_______' ,urn / pm
. am / pm
J '------"'---'
am / pm
am / pm
: am / pm
._~
__~ / ~~ / . I ~_~._.._": ~_............... am / pm ..
.___._~ / _~_~ / , : . am / pm ..
/ / i ._~--~ . ----"-~ am / pm ..
~~ ____-': 1.__......_---'. I
~_ / / ~------,: ~_____.:, , am / pm -
/ , / . : ,__..__... --,' I ,am / pm ..
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SCHEDULE 6 EXPENSES
LIst Items of l;xpense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPI:::NSE VENDOR NAME STREET ADDRESS ClTY
ST ATE
ZIP
Cleaning Kathy 1<e1tbauer .26 .pl.neBr LOOp Hope.Jet. NY 12533
Liquor L ; CE'n~E' Pas+- F)lrll too RJller 119Rt376 Wapp.Falls ,NY ~ 2599
L IlJ.l;C-2B (Ri"_ 4/0.\\
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List all of the single types of games to be conducted at aUlioense periods enumerated in Schedule :).
.
.Note for VeRas Nuda" and Bazauln onlY: The total amount ofprizes 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 dming 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)
'{>z,U}-qL -S f+L-IL
T(JlLez..~ ?O~~
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LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $ 5""'00 "'~
-
at $ ,~OO, H-
at $ '01J (!J ~ l.J-v-
at $
at $
For Merchandise Wheels, Bell Jars and Ratlles, please complete the appropriate spaces 'below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NOLlMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
INDICATE IF TIllS APPLICATION
IS FOR A BELL JAR
LICENSE
YESO NO 0
RAFFLES:
INDICATE IF TIllS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WlNG(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING TIllS CALENDAR YEAR SHAlL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT TIIAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC-1B (Re\'. 3186)
Page2of2
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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
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHAN'CE
LICENSE
GC - rn - [Uili] - GIQLJ - ~
N.Y.S. Identification Number Municipal License Number
Town of Wappinger
Name of Municipality
1195 Rt. 376 Wappin~ers Fall~, NY l?~qn
Address .
After investigation, and a hearing if required under Sec. 192 of the
have been made:
1. All the members-in-charge designated in the appli IOn
character and have never been convicted of a 01" e.
Signature of Person Conducting Investigation
icipal Law, the following findings and determinations
es of c nce are of good mor!l ' ){,..yes 0 No
Title ._" .~hij~tf-.
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. ---;"1;
2.
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 LO be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
~W:r
DUTCHESS COUNlY SHERIFF'S OffiCE
~~O ::::9 "*IlT6M STR[[t
POUGHKEEPSIE, NEW YORK 12601
TO BE COMPLETED BY MUNICIPAL CLERK:
As a resull of the fmdings and determinations stated above, license is GRANTED ~ense is DENIED 0
Signature of
Filing dale of Application 07/07/09 Authorized Officer
KJ Yes DNo
Kl Yes DNo
Kl Yes DNa
19 Yes DNo
19 Yes DNo
Kl Yes DNo
Kl Yes DNo
!I Yes DNo
DYes DNo
Date 07/07/09 Title Town Clerk of Wapping~r
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.
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GC-5
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NYS RACING & W AGERINC; BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE rn
BELL JAR 0
RAFFLE 0
GC - GLJ - ITQ- GIiliJ - ITITLJ
N.Y.S.Identification Number
$1 25.00 II
Amount of Fee Paid Lessor's License Number
This License Must Be
Conspicuously Displayed
During Conduct of Games
Address: 1195 Rt. 376 City: Wappinger!'; Fall R
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Zip Code: 1 ?')qn
Paul Bader
Simon Kaufman
Lewis Hakim
Greg Sarno
LICENSE PERIOD
DATE
08/07/09
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 WHEEL
NUMBER OF GAMES
EACH GAME (Starting Bank)
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
(Date)
(Title of Authorized Officer)
July 20,2009
(Signature of Authorized Officer)
111111\ 11111111111111\ I 1\1\11 -1
L BJ-GC-5 (Re\'. 3106)
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WAPPINGERS LODGE NO. 2609
BPOE OF THE USA, INC.
PO BOX 47
WAPPINGERS FALLS, NY 12590
1005
FOR
DATE 7tJd1
V41" '~ if r I $ :2.3:-
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