The URL can be used to link to this page

Wappingers Elks 2609 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 I APPLICATION TO AMEND (PLEASE CHECK) GAMES OF CHANCE 0 BELL JAR ~ RAFFLE 0 Must be conspicuously displayed along with License (GC-5) (FOR OFFICE USE ONLY) $1 Fee Received (only if applicable) GC -I \ j,j 1-12\ i Iq I-Ilo Ie I~~ 1- []Q]il3LJ I Cl~:(:~:;{~ N.Y.S. Identification Number Present License Number INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY I I Date i lev,''', -i:::<'.. ,..k- ,-./)1/ ,~ \! )..J 1 *-._--"-__/ \'-...... --_~ Street Address Address where games are to be conducted: " '" _~C'" '7 I 0: t;'--l'~.-_-) -t.'~-=_/~._- \l.~_~ ___oj t u=:. Street Address ~~~I~I~~;'Cf:}' t;~d IJ Zi/2:fiC ::::i\_:1Ci.t'~~ County \ ' .\ \ I ' ~,' " I \ \' " - ' /,/.. . _ L I..J-.-J County V*1.rl?\H'f'"( 7711 (0 MUnICl a Ity i Z~3=1( , 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. Officers And Directors yJ Schedule 1. ~' Schedule 2. o Schedule 3. MSchedule 4. o Schedule 5. o Schedule 6. o Schedule 7. 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) 11111111111111111111111I11111 -.J Page I of2 I -, I swear (or affirm): ] . 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 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 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 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 N.Y.S. Racing and Wagering Board. [JiJ / k I (;; I / [ill Date ) . / ,/ /(:10~' ....~. ,-<-;~~ if~ iJ,- SignatUre of the Heatf of Organization /') . <' j/" /-1.-'. ._ fee t~'1 f /t.( j.!\ lZ., I Y', r Print Name }ss V\ i I:' . S, k u I r -5 A being duly sworn deposes and says thatt;)h;:)is the person above named, that s e'has read the foregoing statement and the answer therein noted, and that such answers ar~ and that (s)he has personally affixed his (her) signature to this affidavit. " S~,tOb'~O~~h;' tt dayof {L/~J6, 20~ k} L;'V\,(... cbJVL!: ,) Notary Public My Commission expires ~,20 STATE OF NEW YORK COUNTY OF '" . k- . i-I C /"5 ,.J) v I L \-- 0.. WAPPi~G-ER5 CITY ITOWN/VILLAGE OF Signed Commissioner of Deeds J cO {. To be completed by Municipal Clerk: Issued by (Name of Municipality) (Title of Authorized Officer) (Signature of Authorized Officer) (Date) L B.J-GC-6 (Rev. 3/06) Page 20f2 11111111111111111111111111111 .J sched_l schedule 1: officers and Directors WAPPINGER LODGE #2609 OFFICERS for 2005-2006 Title DOB Name Address Town zi p ------------------------------------------------------------------------- Exalted Rulepamela Kultsar 58 Hillis Terrace poughkeepsie 12603 02/01/1950 Leading Kgn Derrick Mills pawling Lake BOX 17 pawling 12564 10/10/1940 Loyal Kgn Sandra seekamp 67 pawling Lake pawling 12564 12/10/1945 Lect. Kgn Mark H. FOx 28 Tiger Road Hopewell Jct. 12533 09/15/1957 Esquire Diana M. cole P.O. Box 549 Hughsonville 12537 04/25/1948 Chaplain Rosemarie perretta 35 cathy Road poughkeepsie 12603 09/07/1943 Inner Guard Catherine Rohling 54 Brothers Road wappinger Falls 12590 04/22/1940 Secretary Robert M. Acquanita 10 vorndran Dr. wappinger Falls 12590 OS/25/1942 Treasurer Richard o.Desruisseau 183 Red cardinal couPoughkeepsie 12603 11/05/1936 Tiler James Boyer 134 Andrews Road Lagrangeville 12540 11/28/1937 Trustee Patrick J.Moriarty 26 Robert Lane wappinger Fall s 12590 04/16/1941 Trustee JacquelineAlfano 93 Brothers Rd. wappinger Falls 12590 08/27/1938 Trustee Joseph Smith P.O. Box 1972 poughkeepsie 12601 04/08/1937 Trustee Gerhard p.stoetzel 662 Noxon Road poughkeepsie 12603 05/02/1942 Trustee Louis Antolotti 229 Robinson Lane wappinger Falls 12590 06/23/1933 NO officer receives compensation of any kind. page 1 sched_LBe 11 schedule 2. Members in charge of Games LAST_NAME FIRST_MI ----------------------------------------------------------------------------------- Yrs Membe Mills Dana Mills Joan Kultsar pamela DesruisseauRichard ADDRESS city pawling Lake Box 17 pawling pawling Lake BOX 17 pawling 58 Hillis Terrace poughkeepsie 183 Red cardinal courtpoughkeepsie page 1 zip DOB 12564 12564 12603 12603 ...~ .J. ~'. .'. .r. .1. .'. .'. ,,0. n .~ '" " n ,~ " ., n oJ._'_.'."'__'__'__'__'__'. '" n " " ... n " n " "1:'1: *..', ,':,',,,!, *--:. .'..'--'-.'-.'-.'-.'..'-.'. .. " .. " n ,. '" .. " 3 4 8 20 - ........ 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 I FINDINGS AND DETERMINA TION FOR GAMES OF CHANCE LICENSE GC - UEJ - [ili]iJ - ~ - [QliliEGJ N.Y.S. Identification Number Town of Wappinger Name of Municipality After investigation, and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and determinations have been made: L All th, memh",-io-,h"g' de,ign""Ho "'" "ppli6~o /':~~ "f ,banre "eof good m",al ~ 0 No character and have never been convicted of a"crim ;1 /' . ,/ ;,/J ~'/ " .,:,~/" Signature of Person Conducting Investigatio ..' Title 1195 Rt. 376, Wappingers Fa! Is, New York 12590 Address 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 proofthat 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) /";/A- kZf Yes DNo mYes DNa lID Yes DNa ri' Y es DNo u1 Yes DNa ~Yes DNa 0' Y es DNa u1' Y es DNo Ii Yes DNo TO BE COMPLETED BY MUNICIPAL CLERK: / As a result of the findings and determinations stated above, license is GRANTED [!(; license is DENIED 0 Signature of "! 10 /~.. Filing date of Application 3/7/2006 Authorized Officer c.",. L.'~ / / (Municip 1 Licensing Authority) Date -A:2LJ I D (, Titl, T6wN/ CLERK 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 (Rd03) Inl 11I111111111111 uml ~ .. r GC-6 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 I APPLICATION TO AMEND (PLEASE CHECK) GAMES OF CHANCE D BELL JAR ~ RAFFLE D Must be conspicuously displayed along with License (GC-5) I (FOR OFFICE USE ONLY) I GC-[L5]- [ilLBJ-lt.olo 12.1- ~ I OEO:~A N.Y.S. Identification Number Present License Number INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY II I Municipal License Number $Ixxxxxxxxxxxxl Fee Received (only if applicable) I 4/19/2006 Date Nll-ER Name of Organization \\q~ ~..fc 3/Lo Street Address Address where games are to be conducted: \ \q5 ~ -te. 37 f...o Street Address ~Ci~IY-qO- 'rz;II~ Muni ipality /2!Ro Zip ~~ County ctuiLl-e~ County .\'\.b'DD rc'lt'"Y JZj 110 i 2 0=iC\ ~{it:r 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. ~ Schedule 1. Officers And cA1 f ~. Schedule 2. Members In l . P D Schedule 3. Auxiliary! Afj . V J 1 v""l "" MSchedule 4. Assistants To ~. ry t D Schedule 5. Dates, Hours V:1t1/11 ~ Be Held D Schedule 6. Expenses D Schedule 7. Types of Gan Ifany other information furnished on original application is to be chl L BJ-GC-6 (Rev. 3/06) Page 1 of2 1II1II11111111111111111111111 -.J r -, I swear (or affinn): 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 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 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 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 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 NY.S. Racing and Wagering Board. ( , Il Wlt!t( 5.)(k)!SC/,. r- Print Name [ill] / 10161 / IDlhl Date }ss P e. . ,S. \( u IT .5 A being duly sworn deposes and says that~is the person above named, that s e has read the foregoing statement and the answer therein noted, and that such answers are1fi:e and that (s)he has personally affixed his (her) signature to this affidavit. ~::d- day of o...jv$ , 20 ~ S;gn,d , Notary Public . Commissioner omebas . My Commission expires J#L-, 20 STATE OF NEW YORK COUNTY OF =0 LIT LH ~bS WIWPitJG-ERS CITY /TOWN/VILLAGE OF .: {,i' ( -.., Jea.6 To be completed by Municipal Clerk: Issued by TOWN OF WAPPINGER (Name of Municipality) TOWN CLERK (Title of Authorized Officer) Ap r ill 9, 2006 (Date) L BJ-GC-6 (Rev. 3/06) Page 2 of2 11I11111111111111111111111111 .J sched_1 schedule 1: officers and Directors WAPPINGER LODGE #2609 OFFICERS for 2005-2006 Title DOB Name Address Town zip ------------------------------------------------------------------------- Exalted Rulepamela Kultsar 58 Hillis Terrace poughkeepsie 12603 02/01/1950 Leading Kgn Derrick Mills pawling Lake Box 17 pawling 12564 10/10/1940 Loyal Kgn sandra seekamp 67 pawling Lake pawling 12564 12/10/1945 Lect. Kgn Mark H. FOX 28 Tiger Road Hopewell Jct. 12533 09/15/1957 ESjui re Diana M. cole P.O. BOX 549 Hughsonville 12537 04 25/1948 Chaplain Rosemarie perretta 35 cathy Road poughkeepsie 12603 09/07/1943 Inner Guard catherine Rohling 54 Brothers Road wappinger Fall s 12590 04/22/1940 Secretary Robert M. Acquanita 10 vorndran Dr. wappinger Falls 12590 OS/25/1942 Treasurer Richard o.Desruisseau 183 Red cardinal coupoughkeepsie 12603 11/05/1936 Tiler James Boyer 134 Andrews Road Lagrangeville 12540 11/28/1937 Trustee patri ck J.Moriarty 26 Robert Lane wappinger Fall s 12590 04/16/1941 Trustee JacquelineAlfano 93 Brothers Rd. wappinger Fall s 12590 08/27/1938 Trustee Joseph smith P.O. BOX 1972 poughkeepsie 12601 04/08/1937 Trustee Gerhard p.stoetzel 662 Noxon Road poughkeepsie 12603 05/02/1942 Trustee Louis Antolotti 229 Robinson Lane wappinger Falls 12590 06/23/1933 NO officer receives compensation of any kind. page 1 sched_2_Bell schedule 2. Members in charge of Games LAST_NAME FIRST _MI Mill s Dana Mill s Joan Kultsar pamela DesruisseauRichard ADDRESS city pawling Lake BOx 17 pawling pawling Lake Box 17 pawling 58 Hillis Terrace poughkeepsie 183 Red cardinal courtpoughkeepsie Page 1 zip DOB 12564 ********* 12564 ********* 12603 ********* 12603 ********* Yrs Membe 3 4 8 20 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 - CLGJ - [ilili] - [ili]J - ~ N.Y.S. Identification Number Town of Wappinger Name of Municipality 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 ap'plitaao ~ 0 No character and have never been convicted of 'rim, /. 1195 Rt. 376, Wappingers Falls, New York 12590 Address Title Signature of Person Conducting Investigatio 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 gi yen 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) /v'j/'r ~Yes DNo []"Yes DNo lil Yes DNo Ii Y es DNo [If Yes DNo ~Yes DNo 0Yes DNo u1 Yes DNo rn' Yes DNo TO BE COMPLETED BY MUNICIPAL CLERK: / As a result of the findings and determinations stated above, license is GRANTED ~ license is DENIED 0 PiIi'g d"" of Applioatioo 3/7 /2006 ~~,:,~fOflke' s..2(l ('.-1 ((;;I;;;~ /(?!::.1 (MUnici~ Licensing Authority) Date ~2b r D (p Title T~N CLERK 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" _. 4103) ~11Im11111111l111111ll W .J I GC-5 LICENSE TO CONDUCT GAMES OF CHANCE PLEASE CHECK GAMES OF CHANCE IKl BELL JAR 0 RAFFLE 0 GC - [ill] - m;J- GJiliJ - [Q]1]QIiliJ 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 $1 75 .00 II I Amount of Fee Paid Lessor's License Number Municipal License Number The following organization: I s License Must Be onspicuously Displayed During Conduct of Games Zip Code: 12590 Address: 1195 Rt. 376 City: WappinJ!;ers Falls Entire net proceeds to be devoted to the following specific lawful purpose(s): CHARITY - PATRIOTIC - YOUTH ACTIVITIES - EDUCATIONAL Names of Members in Charge HOURS TYPE(S) OF GAMES 7:00pm - 1:00am Blackjack, Joker Poker, BiJ!; Six 7:00pm - 1:00am Blackiack. Joker Poker. BiJ!; Six 7:00pm - 1:00am Blackiack. Joker Poker. Big Six Paul Bader Louis Antolotti Simon Kaufman Lew Hakim LICENSE PERIOD DATE 4/07/2006 5/25/2006 6/02/2006 RAFFLE DRAWING DATE DAY OF WEEK Friday Friday Friday AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes at Fan Market Value) DRAWING TIME DRAWING LOCATION THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED FOR EACH MERCHANDISE WHEEL $ 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 $ 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. TOWN OF WAPPINGER (Name of Municipality) Issued by March 20, 2006 (Date) L DJ-GC-S (Rev. 4/03) of Authorized Officer) 111111111111111I1111111\ 11111 ~ . . --, r' GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE NYS RACING & WAGERING BOARD 1 Waterv!iet Ave. Ext.. Suite 2 Albany, NY 12206-1668 ' . . .J Telephone (518)453-8460 Fax (518)453-8492 ""'-, '~ifW:m';;"~ www.racing.state.ny.us GC- [ill] - [Will.. [8Qli1- [QlilQIill] [lli] I ~ I ~ NYS Identification Number Date SCHEDULE 1: OFFICERS AND DIRECTORS Usr names, addresses and dates of birth of all ofl1cers. If organization is a corporation. or an Jncorporaled or unincorporated association. list officers and directors. TITLE NAMEI~TEOFBIRTH STREET ADDRESS ~S0-1Z. ~y~/_I_1 l I 1_1_1_1 I I 1_1_1_1 \ I 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 \ I 1_1_1_1 \ \ 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 I I I_I _~~.i~1 \ '.4"- Attach additional sheet if necessary. CITY ZIP SCHEDULE 2: MEMBERS IN CHKRGE OF GAMES (MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION) DATE YEARS OF NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP 0W L "A-05-lZ l..:l I 9--0 I r" C; U,L-I!:3d tM-> R~ S Rs2 ~lt\VJil-.L1ll.- ,).S~ 0 LO u \ '-, Atv~ L-1YJ'Tl1 i I J:!L/ ':2:L I I l I ~ q R 01';> I y~' iii '-- t,A ".ttPf, fflH- '- '71 l --- .; '1 0 S~ ~ ,,J ~ f'11 ~ _~'Il.k.. I _:~Q.J --I I ~ C,Oir ~"-' \-rt ' kk" r-;., J (J. I I --;, 0', .'S 1.--0"-'_ 11v\_- I ~ I vI ~I j ~ t\Jul'7 tt;V @tJt.XH~ W A-I ff/.H-c 7 I \?- <)'1 0 \ 1 1 I \ \ I 1=1=1=1 1 \ I 1_1_1_1 I \ I 1_1_1_1 I \ I 1_1_1_' I I I SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXIMUM OF2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN II> NUMBER.) NAME OF A ILIA TE GAMES OF CHANCE ill NUMBER 11111111111111111111111\ 11\ II .-1 L IlJ.GC.2A (Rev. 4/03) Page 1 of 2 @limnu iKaufmau iErna iKaufmau 9 e.nutqlllil!1U 1!iUUI! 1ijnpl!1Urll3JuucUnu. ~1! 12533 Pay to the ~. Order of 50-235/219 561 C)~ u 2499 ')'( 0 Oil( ][)&t"tM c11 ,f ")tJ() ~ l $ is- ~~-- DoHaJrs {D Contains Security Features. Delalls on Back 1'.,. 4... v~~ VtM I: 0 2 . 9 0 2 ~ 21: III 0 2 ? I.. . 0 ~ b 5 I.. III ~~ k~&.1 21..99 M' @CHECK GALLERY, 1995 STYLE # P03 1-800-354-3540 www.checkgallery.com PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS r- GC-2A , NYS RACING & WAGERING BOARD 1 Walervliet Ave. EXl., Suile 2 Albany, NY 12206-1668 Telephone (518) 453-8460 Fax (518) 453-8492 www.racing.stale.ny.u5 APPLICATION FOR GAMES OF CHANCE LICENSE Name of Organization GC- rn - [WBJ - ~ - ~ NYS Identification Number 1013\ 1 \0\7\ 1 @If] Date SCHEDULE 1: List names, addresses and dales of binh of all officers. If organi:z.alion is a cOlpOration, or an incorporaled or unincorporaled association, Iisl officers and directors. TmE NAMEI~TEOFBIRTH STREET ADDRESS ~~t%. ~ ~'fltf-I _I _\ \ 1 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 I 1_1_1_1 \ 1_1_1_1 I 1_1_1_1 I 1_1_1_1 I 1_/~l__1 '1-';\ Attach additional sheet if necessary. MEMffiERSIN CHKRGEOFGAMffiS (M UST LIST AT LEAST fOUR MEMBERS OF APPLICANT OROANlZA TION) DATE YEARS OF NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP \1tuL 13A-lM.~ I~I fJ--O 1~1..iL-\~ ~\.t\)Rff~S R'\)~R}}'M1IUcl-l).-5"'~O L-.OU\S At-.;~L..-Q1r11 ~I Q/~I-U-I ~q RO~I\J4CW L--tJl,\J$-PF', f1H,t.,s,1 l~ s-1 1) S~ ~ tv il1R f11 ~ ~ / -.lk.. / ~ I --I I r. C;ovr,r '1:&.'" \..rl ' ~ f "', :r (J. I I '" 7 7-? ~ LJ1W 1M I-.-:J./~/~I ~ ~ fJu~~vfa-tJ~l,~WItPP.~~~i I?- )'(10 I 1 1 I \ \ I 1=1=1=1 I \ ! 1_1_1_1 I I 1_1_1_1 I I 1_1_1_1 I I OFFICERS AND DIRECTORS CITY ZIP SCHEDULE 2: SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXIMUM OF 2 AUXlLlARlESlAfFlLlATES. EACH AUXlLlARY/AFFlLlATE LISTED MUST HAVE ITS OWN lD NUMBER.) NAME OF A ll..IA TE GAMES OF CHANCE ID NUMBER 11111111111111111111111111111 ~ L IlJ .GC.2A (Rey. 4/03) Page I of 2 r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I List ull members of upplicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a member of IIpplicanl orjl;lIniznlion or affiliate for at least 1 year. YEARS OF MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS (!7lZl1 M11k~) WQ/ _/ _ I _ I I / / I_I 1-/-/-1_1 1-/-/-1_1 \-/-/-1 1-/-/-1- I 1-/-/-1=1 I 1-/-/- I I I ,1-/-/-1=1 I '1-/-/-1_1 I 1-/--/-1_1 I 1-/-/-1_1 I 1-/-/-1 I I 1-/-/-1=1 I i-/-/-; 1 I 1-/-/-' - i I 1=/=/=1=1 I I / / I I I 1- /- /- . - i ;' I \-/-/-: -!l I l-/-/-I-I'~ I 1-/-/-1-\ I 1-/-/-1-1 I 1-/-/-1-1 I 1-/-/--1-1 I 1-/-/-1-1 I 1-/-/-1-1 I 1-/-/-1-1 I 1-/-/-1=1 I 1-/-/-1 I I !-/-/-I-I I 1-/-/-1-1 [ 1=1=/=1=1 I 1_/_/_1_1 1 L llJ.GC.2A (Rn. 4/03) Attach additional sheet if necessary. Page 2 of 2 CITY ZlP 11111111111 11111111111 UIIII .-J Schedule 4 Assistants to Members in Charge of Games First MI Last Name DOB Address Town Yrs an Elk Frank Abato 04/24/1940 39 Kensington Drive Hopewell Jct 8 Philip A Abbate 05/16/1937 6 Hackensack Hghts Rd Wappingers Falls 15 Ralph J Anzivina 12/21/1935 12 Thorns Lane Highland 18 Henry J Boldrin 01/11/1936 28 Gold Road Wappinger Falls 12 Harold A Crawford Sr. 02/23/1936 318 Sunset Hill East Fishkill 15 Francis J DeGano 07/18/1946 27 Brandy Lane Wappingers Falls 15 Roger DeJordy 09/19/1944 83 Kent Road Wappingers Falls 15 Richard 0 Desruisseau 11/05/1936 183 Red Cardinal Court Poughkeepsie 18 Richard D. Dobbins 05/30/1949 6 Schuele Drive Wappingers Falls 19 Stephen F. Drobnak 02/02/1957 53 Moccasin View Rd. Fishkill 6 Robert Fischetti 06/07/1926 91 Ardmore Drive Wappingers Falls 25 Mark H Fox 09/15/1957 28 Tiger Road Hopewell Jct. 11 Harris C Jones 04/24/1944 217 Brothers Road Stormville 15 Robert J. Juhano 10/05/1953 2776 West Main Street Wappingers Falls 10 Joseph Junna 02/28/1963 173 Hillside Lake Rd. Wappinger Falls 7 William K Mmkowski PSVP 03/20/1942 427 McGrath Blvd. Fishkill 25 Eugene P Pampalone 09/03/1936 53 Helen Drive Wappingers Falls 17 Rosemane Perretta 09/07/1943 35 Cathy Road Poughkeepsie 5 Gregory F Sarno 07/01/1936 13 Dana Place Wappingers Falls 25 Kenneth J Tucker 03/19/2029 34 Pawling Lake Pawling 6 Robert N Wallner 01/17/1933 7 Kinry Road Poughkeepsie 16 Schedule 1: Officers and Directors WAPPINGER LODGE #2609 OFFICERS for 2005-2006 Title Name Address Town . Zip DOB ---------------------- ----------------- ------------------------------ ---- ----_. ---- Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957 Leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950 LoyalKgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940 Lect. Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945 Esquire Mark H. Fox 28 Tiger Road Hopewell Jet. 12533 09/15/1957 Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948 Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943 Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942 Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936 Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938 Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04116/1941 Trustee Paul U. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965 Trustee Harris Jones 102 Brothers Road Stormville 12582 04/24/1944 Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 05/02/1942 Trustee Louis Antolotti 229 Robinson Lane Wappinger Falls 12590 06/23/1933 No Officer receives compensation of any kind. r GC-2 I FOR OFFICE USE ONLY APPLICATION FOR: PLEASE CHECK GAMES OF CHANCE~ BELL JAR 0 RAFFLE 0 -------.-........---...-- ...-.-----1 $\ 75r~!!- I [illJ/~/~ ! Municipal License Number____J:.~e~J~.:~::~~~_u...__.____.___~~----..---. NYS RAC1NG & WAGERING BOARD I Walervliet Ave. EXL, Suile 2 Albany, NY 12206-1668 Telephone (5] R) 45:1-8460 Fax (.'i 18) 453-8492 www.racing.slale.ny.us , i INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY GC-[illJ-~-[0Q]ad- ~ N Y.S. Identlficiltion Number IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION -('~ U () ~ w A Pp \ \J~l2.. \)VTcrttZ. S G.;:> Name of MunicipalilY County \ PART A, GENERAL I. Name of Or 'uniwtion 3. Has applicarll e\'t:r been denied a games of chance license? 0 Yes )tlNo If "yes", why'! (Attach ex Ira sheet if necessary) 4. Clleck lype of organi1.illion and. if applicable, give the State find datc of incorporation. Cocpu/C.llillil 0 I ncorporaled :\~~Ocialion ~ Stale incorporated jJ$4..'l '( t) Q \L .. Dale ~[J / [O--rG / lII] Date [1_] / rn / rn U nl ncorporalc'(j Association 0 Slate incorporated Individual o 5. Did your curponHe slatus change since your identification nU'jber was assigned? 0 Yes ~No 6. Art' vou doing bllsint.'s~; under a trade name? 0 Yes 0 No If "yes", what is the trade name? PART B. LOCA nON OF GAMES <J 71 .J 7. Address where games, bell jar. or raftle drawing(s) are 10 be conducted. JJ q 5' ~ .} ~ U; PR p, F-IfL.J~ \J .' ~ 1 ~ Name and :.lddress of authorized games of chance lessor renting to applicant. tJ/Pr '-} Does the appl1canl own the premises') ~cs o No If "yes", how long'! 1 U. CapacilY lor public assembly of premises presently owned or occupied, ------.--- d-~~ 11 Have premises been regularly used? ~es 0 No If "yes", how long? (1 i r2f\-~ ~- Are games of chance being played now on these premises nr ha'\ il ever been? ~ Yes 0 No If "yes", give full details. Q(3C,,'O').1 J.-ooC; !:2 Are the premises or any part thereof where games of chance are to be played licensed by the Stale Liquor Authority'! tp.,Yes 0 No If "yes", slale the lype of licc:nse and rlUmher cL -- ooo7lf- J l(~ 13. Has sLlch lici;nse i;ver bet:n If "yes", why? (Explain on a separate ShCi;I. if necessary, and attach.) revoked ur suspended" 0 Yes ~o L HJ-(;C.2 lR~v. 41U3) Page 1 of2 11111111111111111111111111111 .J I' I J'!\Irr ('. l'l'I{POSES OF (;,\i\IES " ~:~I' [;;i(' ~~"R'\'rt; ~'" ,.,,, i" '''' :'''''''1- Gh~ J;~~l ;TI;~;' L;"" .-.-..,----.----.-----"" ---~-----~..,_._.- I SW,';II \UI dllllllli Ttl~l AU I tic "lladled \,'lll'lillk~. :IH' :l Illillt'l'liil 1"111 IWleil[ dilL! ill t' ill,:<ll p\ildlt,d tleleill liS iI'sd (Jill ill filii 111 Ihe. appllClIlluti. All the answels .:"Ill.lilled 11\ Ihis llpplldllUlI die it JlidllTi.ll pllll hrltuL !ll<ll ,he; clllite Ilel Pl\h.',:t1h ut all gUllle:> uf dHU1C': shull b~ devuled ".\c1usivV'iy to une llr more, u[ Ihe "lawflll pllrpose~" as uetined in [he Games l'f CII<.IIlCe LII'I'U'1l1f', I.,il\\' <.Ind Ine kulcs lIlld Regulations Uflh.: Hildll\. \, I1!at tUI CJell iil'~lbC: !K'w'd 101 wtlich II Ikc',11Se. is SIHIgl1l. (lilt 0' IlIUlt d ltle adIY" 1lll'll\bel~ Illldel whose sllpclvisiuiltl1e game:s are [() be: held, UpCIlllCll .tlle! u.mJu';kd, whu i, lumili,u with lh'c Games 01 CIHlnte Ltcellslllg Law, the 1{1Iks umlReglliallons of the N. Y.S, Kacing & Wu!:\enng bUUld ;111<,: IlKui 11,:CllSlll!; ')I<1in;lIh,:es ur luws. will he prl,:s'~llI ,ll allllllll:S, ill dlUlge and plL\\arily le:,pullSilJk fUithc conUlltl of games, 4, lIJi.l\ ltl" ullderslgned wili tll' r"spullsil>k I'll!' the holding, up"nHlull ami ciJlldllcl "I' all gUIIlI,:S ul' dlancc: ill aceurdallc'~ wilh lile terms of the: hteIlS~, the ill' "lsIUI\' uf thc U.llIlC;' u1' ('haf"X LiCCll:iJlIg Law, the Rules UIIl: I{cgub! iUlls o[ llle f\;. y ,S, Racl ng ,,>< Wagenllg Huard aml witl] the p' uv ISIOns ul \l)~'alli(t:llSIl\g (.Jrl1iJHUll.~CS ur laws ~, 'I tldl \tIe IJH,krslgll<;Jd llits n:i1J lllld IS t'alllilLII w.lth the prilvisiollS lil' Ihe (Ialllc:, lIi Chlldce Lic<:lIslllg LlI;. .IS UJIlcIJldcd, the Rules alld Regllliiliol1s ,:I Ihe ~;,l ,S, H.,KilIS s: \\.tgellllg ll,'wll. am] lite local ti~llll'Jf\b 'lfliJillII\C1\' \II' bws, (, l'hutlill '.'Cl\II111I,~:u1\, 'ULil')', Clllllpcli,nUc1ll, reward or 1~~Ullll)l;lIlSc~ will (11:' p,m!1O allY per"lll 1'01 tJOldlllg or a$SiSLillg 11\ the uperatJng or '>)1\duCJll\g llf tile gUllle'S, ,,)(L'CVt to houkkc,eper, III i.lCCDUlIlal\ls lur pItJ;CS~I(liIUI services ill UIIlIII1UlIIIlllUl C\cceding thut nxeu by the BOllrd. r"Ol3-! / I 0151 ! !r'~;1 ,_ ___..L_. c,__~~! l,~L_1 rJalt' . ~ /;;L()~._.~ STe~f>~~,,~.])((vt9~ It~ or' lk:ld 0[' Ll!ic,dJlimlioll Frilll Jllle ,'; i\ 11: 01 ; NF\V YORK }ss ( (Jl'NTY ()[ 9\i\C iL~S7 ~."...._._ll.__-......~__,~..- ClTY;'11 iWN/VILJ,/$J! I) l: "~---_.._--......-----_."-->-..-...,-......--- ) ,__,_._,,__,_____,- ".. . .." . $~Ing Clul) s\\orn deposlls and say,s thell ,S)IIe, i:; tlie per:,0Illlbme IHlll\ed, thlll i" ihV' hll" read lhc'f,:,reg:j';;;g :'l';~t:~l;~;i'I(:toJll1:;7;1'1:,,\\:er tlten:lllllulcd, I\lld lhat SlIdl ;tllSWers arC! I rut' llllt.! thaI (s)htJ has person&lly lilJl.wcJ lu\ IJ:~'J! SlSIli.llurc:u this allrda\'Jl, SW<)!II tu [JdDl'll Iii": [hi" 1.~- day ill ~JL_, 2() /J;l i. S,g=~l)vw. CJnt1J1~ O_~-'--'-----:~'~Iar\ l.luillic,------- Mr C""mw.,,,,,, c>p;r" -.:-~;'J.'f.(;,...-..' ill Commissioner ui' Deeds L 11.1,(;('-'; (i,l'Y. ol/UJ, l\lfl' 1 1l1'2 III \ 1111111111111111111111111 .J t -, I GC-2B APPLICATION FOR GAMES OF 1\'(>; RACING ,I{ WA(iFRIN(j BOAl\!) CHANCE LICENSE I \\alervliel AVe. Ex.t., Sllllc::' AIIHtIlY, NY i22()6-lhhK 'l'ckpllllllC (51 g) 453-84110 hlx (5] 8) 4H ~W):2 Wv.iW. r:dl:lI1g. slall~.I1Y .us *' ( .' r._, ." ,.... ~. \ ih .,. .. '\';'-_~.8c:mf - ...-;.# \'~ l\-\\J \ f _~I~I Name; 010rganizatlOl1 GC-[illJ - [l[ill] - l_~ () l2d - ~ 1\ YS Identification Number ~1~ 1 / [d1J / r-ol~--1 Date SCHEDULE 5 DATES, HOllRS AND RENT OF ALL LICENSE PERIODS TO BE HELD (NOT APPLICABLE FOR BELL jl1R GAMES) DATE . I-fOURS _~I ~I ~~_ ~~_~:J:.!~aIn/@-I,CO,:~__@/PInI$. ~L / 05"", / 0 (; __ ,: '7'.~aIll I~- 1.::!L: @/pm i $ ~~, / 0 'J.-, / 51 'G , ")',.OO,am/@9 .. ,l'.~U ,:, @/pm 1$ , / / ,am I pm - ~.,__--,:~.....-o---' am I pIll I $ ~ / ~_~ / ,----,---,! am I pm _ , alll I pill i $ , I / i : am I pm - : am I pm I $ '----'___....J ...__._..._____, ,___._............._, ...___--"_..._.l ..__..Io..--.--_~ '----.l.~ ~~ I.. ~. I ~~ ! _~ ' ' ~~-,arn I pill - , : ,_____'_--, am / pm i $ ~._~ / / , ~ . ",--,--,ani I pm - ~-'--' ' ,ani / pm I $ ~ ~___~ / ,___~__~ / ~_~ I ,_.__~__~: ~~---,um I pili - , . ,am I pm : $ , , / .______' / ~__~' _________. ,am I pm - I ~_~ , amI pm I $ ~_ / , / '-~ ' .am I pm'), '----'-_. : '-~ a 111 I pm I $ / . / ~_~ I ~_--,-"",,: ~_---,am I pm ~. ~..-,--,,: ~~am I pm ! $ RENT () 00 J \1... ' d,.!2_iL o .() D , ' ~ ..........-----..--' .--.... J ____....--' -,\~--' , . --------" PRIZES (Cash or Fair Markel Value of Merchandise I !$ !$ i$ 1$, :$, RAFFLES DATE TIME am I pm . am I pm am I pm - . am I pm ~---"'-~ ._~~.-~ ~~,---,' ,__---'-~arn I pIll am I pm ,am I pm ~~ / / . ~___'__n~: ~~ am I pm - I / am I pm .. ..__...._.__.... '--_~ __---' ~---,"__ _..... ~_ _A-_--i _~_I / " / ~~ / ~_...' ~-"--~_.~: , , / , / 1-_ n__...._........-..I ~.o-~ .' '-I . \-...,..~.__.""-- __t . L.__~ . am I pm .\.....-~ '-_~__.J SCHEDULE 6 EXPENSES List Items of expense to be incurred. and the names and addresses of persons to be paid. ITEM OF EXPENSl: VENDOR NAME STREET ADDRESS CITY STATE ZIP cJ...'~,4.v i\)t- l<1\11H Rfir1 &(}U~fL '){, ?\\J~ ~ocv..-Lco r llorf. :JC\ tv:i. ~ )-Sz, ~ L-lQU 0((. \) Oah ~ Pl17r fi1...~{) r-~ f-\:2,'7<o tt.Yrf f ~'? \<J{, _L'2::--S5 0 - .....--------~--- -". L Ilj-ljl.'.2U (Re\'. 4/1J:\l [-'uge [ ()12 11111\ I 1111111111111111111111 .J , r'SCHEDULE 7 TYPES OF GAMES I List all of the single types of games to be conducted at all license periods enumemted in Schedule 5. Note for Vee:as 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) ~l~t~Jtt-UC 76 ((fiR fa (~D- ~162- Sl~ w\t-ft-(t 1.-- 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 ., . r.t' BELL JAR: lNDICATE IF THIS 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 PRIZE SHALL EXCEED $500 RAFFLES: INDICA TE IF THIS APPLICATION IS FORA RAFFLE LICENSE YES 0 NO fJ--. 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 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.ZB (Rn. 4/03) Page 2 of 2 11111111111111111" 1111111111 ~ TOWN OF WAPPINGER TOWN CLERK CHRIS MASTERSON 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 (845) 297-5771 FAX: (845) 298-1478 March 10,2006 Adrian Anderson, Sheriff 150 North Hamilton Street Poughkeepsie, NY 12601 Dear Sheriff Anderson: Enclosed, please find a copy of the members of the Wappinger Elks #2609, Route 376, Town of Wappinger, who will be conducting Games of Chance on April 7, 2006, May 5, 2006 and June 2,2006. ,. v of the .Members in Charge" listed on the application. and Determination" form attached and return the form <t t-- ~\ ~ <t ~ :! '~ (f '-..j ~ CL this request and your prompt reply. ~, a\ ~ \ \ ~ ~ ~ FORM GC-5 Form Approved By: NYS RACING & WAGERING BOARD BUREAU OF BELL JAR & CHARITABLE GAMING COMPLIANCE 1 Watervliet Avenue Extension Suite 2 Albany, New York, 12206-1668 LICENSE TO CONDUCT GAMES OF CHANCE This License Must Be Conspicously Displayed During Conduct of Games Identification Number (from requisition form) GC13-219-602-02013 Municipal License Number 0603 Name and Address of Lessor: Lessor's License Number: AMOUNT OF FEE PAID $75.00 Licensee's Name: Address: Waooinaer Elk's Lodae #2609 1195 Route 376 Wappingers Falls NY 12590 Type of License: 121 Games of Chance o Bell Jar o Raffles Entire Net Proceeds to be devoted to the following lawful purpose(s): Names and addresses of members in charge of conducting games: Paul Bader Louis Antolotti Simon Kaufman Lew Hakim LICENSE PERIOD DAY OF WEEK HOURS TYPE(S) OF GAMES DATE 4/7/2006 Friday 7:00 pm to 1 :00 am Blackjack, Joker Poker, Big Six 5/25/2006 Thursday 7:00 pm to 1 :00 am Blackjack, Joker Poker, Big Six 6/2/2006 Friday 7:00 pm to 1 :00 am Blackjack, Joker Poker, Big Six RAFFLE DRAWING DRAWING AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes at DRAWING DATE TIME LOCATION Fair Market Value) THE MAXIMUM AMOUNT OF PRIZES TO BE THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED AWARDED FOR EACH TYPE OF GAME OF CHANCE FOR EACH MERCHANDISE WHEEL NUMBER OF GAMES NUMBER OF WHEELS EACH GAME (Starting Bank) EACH WHEEL THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR GAMES SHALL BE PLAYED IN ACCORDANCE WITH DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE STATE LAWS AND RULES AND LOCAL ORDINANCES PRIZE SHALL EXCEED $500. OR LAWS. ISSUED BY: Town of Wappinger (Name of Municipality) DATE: 03/20/2006 (Signature and Title of Authorized Officer) GC-5 (Rev. 12/94) r,,' GC-2 -, r I I i L FOR OFFICE USE ONLY Municipal License Number APPLICATION FOR: PLEASE CHECK GAMES OF CHANCE IQ BELL JAR 0 RAFFLE 0 ---------.-----.'----------- _.-----._---~ $[ 7S:'?'~ I [ill] / 0ZJ / ~ \ Fe_e.~_~~!::!~e~__._____________ Date j NYS RACING & WAGERING BOARD I Watervliel Ave Ext., Suite 2 Albany, NY 12206-1668 Telephone (51 R) 453-8460 Fax (518) 453-8492 www.racing.state.ny.us INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY GC- [illJ- ~-- ~- ~ N,Y.S. Identification Number IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPI_ICATION -('~ U 0 f- UJ ~ Pp i \J~l2.. \)UIC\1~ s S Name of Municipality , County 2. 3. Has applicant ever been denied a games of chance license? 0 Yes J,t,No If "yes", why'! (Attach extra sheet if necessary) 4, Check type of organization and, if applicable, give the State and date of incorporation, CorpOnltj(ln 0 Incorporated Association ~ Stale incorporated y~~') "lo l2- \L __ Date [i[J / ffll / lRI] Date 0-=] / rn / rn Unincorporated Association 0 State incorporated Individual o 5. Did your corporate status change since your identification nu,ber was assigned~ 0 Yes ~No 6. Are you doing bllsillt:~~; under a trade name? 0 Yes 0 No If "yes", what is the trade name? PART B. LOCATION OF GAMES - ...., '-~ 7, Address where games, bell jar, or raftle drawing(s) are to be conducted, JJ q ~ ~ ~ 7 ~ wAf f ~ \-1.' \ " 8, Name and address of authOlized games of chan<.:e lessor renting to applicant. \J/A- \ 0, Capacity for public assembly of premises presently owned or occupied. -------. J-rg ~ 11. Have premises been regularly used? ~es 0 No If "yes", how long? l1 i ~t+~ 2-- Are games of <.:hance being played now on these premise~ or has it ever been? l'Sit Yes 0 No If "yes", give full details, Q0C:. () ').1 J. 00 C; o No If "yes", how long'! 9, Does the appl1cunl own the premises? fI.:! es 12. Are the premises or any part thereof where games of chance are to be played licensed by the State Liquor Authority? ~Yes 0 No If "yes", state the type oflicenst: and numher. cL -- OCOl If:- J l(~ 13, Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach,) revoked or suspended'l 0 Yes ~o L BJ-GC.2 tRev. 4/U3) Page I of 2 11111111111111111111111111111 .J I r' 1',\I{'l' C. l'lJRl'OSES OF t~A~'lES '" ~::J Z1;i~' tJ'l{t\;~" ""i,,, "" I" '''''1-11'; b~ J;~~ ;T;'VW:::'~"" -- I swe'li [UI dllirllll nl~1 ,'\U. ttlc ullaclied s,:llcdllk, an':\ Illillr.i'lal \\ilrlllL',lcul'dlld "I" IIlCUlp'lIdlec! IICICill 'IS it stl \JUI ill full ill tlicapplictltlulJ. All tile allswers ,'''lll.lIlleJ 1IIIhis uppliC,HIUII Ml'. illll,Hni:!, ptUI!ICIWl. Thullhe clllirc II~I Plul',.cds ,)1' 'Ill gUIll\::i of dHUK'.\: sltull bl;j dcv0tcd t','\du,ivdy tll one l11 more olth!: "li.lwllll purposes" as defined In toe Galllcs ul CIi~I:"c Lil'L'Il>lllg 1..<iW anJ lilt; Rule, am! Regulations 01' the B\HlI\1. TI!~1101 eal'lltll'cnSe p<:'rll.'d tell wliich illicllllSC is sought, Ullt Il! nlun:. Uf!llt:.lII;livt; IIIClllbels Hlldel wllOse. SIIpC1Visillll tlte games are to be ild,:, ,jf.l<:I,lled alld ,unJu.;t.;J, Willi is fumjli~l with III'': GUi1\~S 01 Chilnce l.icenslllg L~w, the !{ult:, ~Ild Keguiutions 01 the N, Y ,5, Kaeing & Wugerlilg L,UUld and luculliccnsln!) Ulllinallcc, Dj' laWS, will hI' pl\:selll 01 i1lllillles, ill dlalge alld plinldlily le,pulIsibklUltl1e \':ll1\lJuC:1 of games, IIIJ! III, Ulld~l'lg.ned will Ill' 1'~'pUIISillk Iuj' the Ilnlding, lIpemtion ilnd WlIelm;1 III illl bdll\t;, ul' CIIi.UICe III accllrdillll'c willt lite term> or' the iICCII.;~, ilt~ 1)l,."ISiuII' Ilf lltc UalllCo ui' Cltilll(l' Uecn>llIg Law, Ihe l-luks <llId RegLlI~lilll\s olthc N.Y.S. IClclllg II.:. W.lgenng Huard ~ncl wilil tile IJII1YISIU'" ,)1. ~\)i,:;li lil'Cll:');lIg l..lnllHaIlC{~S UJ' la\vs '1 lllil!lle uIIJel'Sll:\llcd hilS rt:i1d and IS !'ul\tiliur WHO tile prllvisiollS Illlrl'~ C'lilllllS ,11 C11~llll'l;: LiccllSillg L.IW ciS HlIIllllded, Ille Rllks and !{eglllli\lUII, ..11 lilc ~C{S 1~"l.:in.,. & Wli)i.c:nng llllwd, ulldtlte locullleensing llldlnullecs or l:lWS. -'. 4. ~, (I. Thai Illl ,:lllnllIlSSlun, SUI:ll'y, ,"ll1\PL'.II'lltlllll, reward or rtl<;ompl;\llSc will btl p~tld 10 U1\)' pcrs0n for 110ldlll~ 01' assj!)lillg In the operilllng or ,.,ncludlng ,,1' lilt: galll<:s, <:xel'pllO bl.lukkc..epers lll' ace,OUlllallls rur 11IIlressioillli servilees ill .i11 ,1I1101l11l11ut c.\l:CeJillg [bUl t1xel1 b)' the lL);\ic!. ~l~j / [Om / [(~-\~:] .~' ~, UUIt: - Sign; $r,;ih<~ f_])R()K$,J.k; !'I'illl ;J!llc :'\1\ 11; UJ' NEW YORK }ss i.UU~TY UF' \)\i\Ci1.4 ~7 _.__Jl...!:::..--~.- U!'l'TUWr\/VILLI\Ul U!; ..---.--.--..---)-. __....__._.______._ . IH,;ing duly swurn depOSeS and S;lYS th,11 (~)Ile IS the person abuve IlJIl\ed, lltal \"ill,: lius IClld Iltl: j'ulc!;01:ig Sl;~l;::W~;';l:;i\Jlh~:.allSi.~ llieleilllluted, all(! tllat suc:ll answers arl: lrut' alld tllilt [>)Ilt:. has p<:rsUII<ll'!) alJ],wd Ill'> (1:<:,1') ,lbll~llln: tu tilis allldaVll. SW"1 II IU IJd>lre JIll: Illls .J.~_ (by 1\1 ~J., 7.00b Sig,,~Q. -- --..,.....--- COIl1Jl\issiOf\\.:r lie Lk,:Js )\,ilM\ PubliL . M, e"",,,,,,,,,,,, "pi,,, _ll}l~._. 20 , ~ ' ,':,'If.')n;~i' "<, at> L BJ-l;C.l (Hl'Y, 4/0.11 i-'Ugl' '2 \,)1" '2 \\111111111111111111111111111 .J --, .r.- GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE NYS RACING & WAGERING BOARD 1 Watervliet Ave. Ext.. Suite 2 Albany. NY 12206-1668 : J Telephone (518) 453-8460 Fax (518) 453-8492' .~~ '" ~..;I _Wg~'; Name of Organization GC- rn - [RiliJ - ~... ~ @ill 1 [lli] 1 ~ NYS Identification Number Date SCHEDULE 1: OFFICERS AND DIRECTORS US! 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 I~TE OF BIRTH STREET ADDRESS ~SfllZ. ~ ~o/i+-I _I _\ I \ 1_1_1_1 \ \ \_1_1_\ \ \ \_1_1_\ \ \ 1_1_1_1 I \ \_1_1_\ \ I \_1_1_\ \ \ \_1_1_1 \ \ \_1_1_\ \ \ 1_1_1_1 \ \ I_I --..i-.-I \ '. ~_." Attach additional sheet if necessary. MEMBERSINCHlRGEOFGAMES (MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION) DATE YEARS OF NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP 0W I- ~ J\{JaR I ~ 1 !}-O 1 r" r; 1-U-10::J ~ R~'" S Rt> ~RJl.\YV I ulll- I). '>'t 0 1-0" \" lWIl1 L-01T1 I --k... 1 ~ 1 ':2L U-L_I ~ ~ ~o"" I:IJ~O l\I lc-/V 1,~Pf, 1"1l-t 1., S 1 1:J.- C; <10 S~ fY :t fl1 tW '8 1 _lle_) 2!L 1 ...f: I ~ c;ovr;: ~\O \..tf ' lit\' e:., :r cJ. I I -- .,- ~ ? L.-r1w _ [<I "" I i/'2;]) ~l 3 ~ - 6J"V7 ii,v ~ L~ W Il-I f fiH,.;. 1 I?- <;q 0 1_1_1_1 \ 1 i 1_1_1_1 I 1 1 \_1_1_\ \ \ I \_1_1_\ \ \ \ 1_1_1_1 \ \ I CITY ZIP SCHEDULE 2: SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILlARY/AFFJLlATE LISTED MUST HAVE ITS OWN ID NUMBER.) NAME OF A ILIA TE GAMES OF CHANCE ID NUMBER \111I11111111\1I1111~ IIIIII1 .J L 8J.GC-2A (Re\'. 4/03) Page ] of 2 . . r'SCH~DULE 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 IIpplicant orjl;lIoization or affiliate for III least 1 year. YEARS OF MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS B~1 M1FKtH10 L{Q 1 _ 1 _ - \ \_1_1- - \ I 1 1 \ \ \-1-1- \ - \ \=1=1= I = \ 1_1_1_1- \ I 1 1 \ \ \-1-1-\-1 ,1=1=1= I = \ 1_1__/_1_1 \ 1 1 I \ \-1-1-\-\ \-1-1- \-1 \-1-1- \-\ \-1-1- -I 1=1=/= = I I 1 1 I I - __ - _I I 1 1 I ! \-1-/-\-1 ;. \-1-1-\-\" \-1-1- \ -I ,~ 1=1=/= I = \ _/_/_1_1 _/_/__1_1 I 1 1 I I 1=I=l= \ = I III \ \ 1=1=1= I = I I 1 1 I I 1=1=1= I = I 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 CITY \ \ \ \ \ \ 1 \ \ I I I I \ \ \ \ I I \ \ I I I I I I \ \ I \ I I I I ZIP , I I i I I I I ! I I I I I I I I \ I I 11111111111111111111I1 UIIII ~ Schedule 1: Officers and Directors WAPPINGER LODGE #2609 OFFICERS for 2005-2006 Title Name Address Town . Zip DOB ---------------------- -------- -------------------------- ------------------------------ --- ----. Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957 Leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950 LoyalKgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940 Lect. Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945 Esquire Mark H. Fox 28 Tiger Road Hopewell Jet. 12533 09/15/1957 Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948 Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943 Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942 Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936 Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938 Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04/16/1941 Trustee Paul U. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965 Trustee Harris Jones 102 Brothers Road Stormville 12582 04/24/1944 Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 05/0211942 Trustee Louis Antolotti 229 Robinson Lane Wappinger Falls 12590 06/23/1933 No Officer receives compensation of any kind. Schedule 4. Assistants to Members in Charge of Games First MI Frank Philip A. Ralph J. Henry J. Harold A. Francis J. Roger Richard O. Richard D. Stephen F. Robert Mark H Harris C. Robert J. Joseph William K. Eugene P Rosemarie Gregory F Kenneth J. Robert N. Last Name Abato Abbate Anzivina Boldrin Crawford Sr. DeGano DeJordy Desruisseau Dobbins Drobnak Fischetti Fox Jones Juhano Jurina Minkowski PSVP Pampalone Perretta Sarno Tucker Wallner DOB Address 04/24/1940 39 Kensington Drive 05/16/1937 6 Haekensaek Hghts Rd 12/21/1935 12 Thorns Lane 01/11/1936 28 Gold Road 02/23/1936 318 Sunset Hill East 07/18/1946 27 Brandy Lane 09/19/1944 83 Kent Road 11/05/1936 183 Red Cardinal Court 05/30/1949 6 Schuele Drive 02/02/1957 53 Moccasin View Rd. 06/07/1926 91 Ardmore Drive 09/15/1957 28 Tiger Road 04/24/1944 217 Brothers Road 10/05/1953 2776 West Main Street 02/28/1963 173 Hillside Lake Rd. 03/20/1942 427 McGrath Blvd. 09/03/1936 53 Helen Drive 09/07/1943 35 Cathy Road 07/01/1936 13 Dana Place 03/19/2029 34 Pawling Lake 01/17/1933 7 Kinry Road Town Hopewell Jet Wappingers Falls Highland Wappinger Falls Fishkill Wappingers Falls Wappingers Falls Poughkeepsie Wappingers Falls Fishkill Wappingers Falls Hopewell Jet. Stormville Wappingers Falls Wappinger Falls Fishkill Wappingers Falls Poughkeepsie Wappingers Falls Pawling Poughkeepsie Yrs an Elk 8 15 18 12 15 15 15 18 19 6 25 11 15 10 7 25 17 5 25 6 16 ,,- . GC-2B --, NYS RACiNG", WA(J'RINC IlOAIW i \\a(eiVli'~1 AVe. Ex!., SlIIlC.2 \111<-111], NY 122()6-lhhK Tekphon<: (5 j H) 453-l;4(l() hlx (5 ill1 45-' ~q(>:2 www.racnlg.slille.ny.lls APPLlCATIONFOR GAMES OF CHANCE LICENSE ." ( -', i (', r /. 0~~" Jt ,; l~__ _.,-" GC- ~_I~l.- [HJIiJ - GLilij - ~.1J-l 0 L!TIJ NI'S Identification Number ~T;;] / rO -\ -7 1 / lol~--l Date SCHEDULE 5 DATES, HOlJRS AND RENT OF ALL LICENSE PERIODS TO HE HELD (NOT APPLICABLE FOR BELL JAR GAMES) HOURS --~-< ~~~t::;~ ~f~\- ~~; ~:: I $$ '-----'- . ' ____L-......--' ~ ~".~ ,---.-1-.--__ ,----+--_~:, '] \.170,am /~. t' ~iJ ,:, . @/pm i $ . ________. '- ,am / pm '------'._._~: k.._~~ am / pm i $ ~ k.............--'. .am / pm .. ,am / pm : $ , ~_._....__,' ,____~~alll / pm - ~--,--,: '-~ am / pm ! $ , ' ~_____~. ~~--,am / pm ... . .: ,,----'--_.am ; pm i $ '-._~_ , . '--""'"_---'am / pm . '--~: ~~aln / pm $ ,___._~ ___~ . k___~__.am / pm. , : ,----,----,am / pm $ L .__~ : _~ am / pm - ~_~: ._~" ami pm I $ ~~ : am / pm- : am / pm I $ 1..--___-,-_-01 ~---' ,~l-~_~ L-~ . I ..---' _..~: _~._.ym / pm ~. k~" ~ : ~.. ym / pm J: $ RENT c)"L 0 () C) , CJ () I t,.,..-.____---' {) (J D . ~ .. ...---0.--1 . DATE ~___:j." / ~_J / 9_~_ 'J / 0 S- I () lp ~C;~ / . 0 "J-' / ()-"G~ ......~_J .. l.~__--"---..-.l / . I ~..--'------' / ~._~--' I '----'~ / I I t...-~_I_..__...J ...,_._..."......~-.-_I ,.......__.-~-.-._-, / I ~,.. \-.---'----' ....._~--" / / i ~-4.--------.I ~-' '----..-~ / I "'-_---'---.__--' L__._,__.....__.~_--I ...._.+_._..L---.-..,.---.--.J / / ........____---' 1.---'0__.--1 ,-__.___..-J / I L..---~I ~..lo---J '---'----"' I I .. ~ L -.1..---' 1.<--...... -.-...... .......-----' L ---' ' ~..'----__---"-_.._._....J ..--.... ~ .. '-----'-----' -' l..-~-' PRIZES (Cash or Fair Market Value of Merchandise) :$, !$, i$ , i$ , :$ L RAFFI.ES DATE TIME . am / pm L."..~_.l-._+_'" ,___._....J....----I ,__~.._~ . .___-<-_~ am / pm , . '-----"--~ am / pm .' .am/pm ~~,' ~_~_._}.\In / pm / / am / pm - L.-_.____....1 '---~ ~ . I L-.__ .._..._"_..._.... ,--~--ol__..I / / . am / pm .. L..-___+._~--' '---_......._..-.01 __~ ...__-----'-..__....__..1 .. ~_.._._...-4-_.~, / I : . am / pm - ~-~-. / ~~ / '------'~--' ! ~---._--.: ,---,,---' am /pm ~--" ""'-"--'----" ~.._.... I I."_,~___..L.___.---.J" I , / . / . . '-_'dO_ _.' L,,___~_' am /pm ..~._~ ,"~~ SCHEDULE (. EXPENSES List 1 tems of expense tu be incLlrred, and the names and addresses of persons to be paid. ITEM OF EXPENSE VLNDOl{ NAME STREET ADDRESS CITY STATE CJ-I::JV 1\)6:'" l~lYffii Ran &11-u~1L ~?\\.i~ ~OC\lL.t() r lJ-vrf .Jcr tv .''t . L-ltlO o~ ~l eft L~ rz.;.. P Il9 T- l7f..~o p.. ~~ d q 5' it\: 2,'M ~M f {Z-Il-U'7 tJ .~ . ZIP ~ }SZ, ~ lr~~ 0 ........--......-.-...-.-....--.-...........------~- --,--.._--------._.~--------~- L llJ-I;(,.W (He,'. 410.\1 Page ! ill 2 \\1\1\ \ \\1 ~ \111\ \ 11111\1 \111 .J . . r'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 Veeas Niehts 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 (Umit: 5 Games) ~ ~tV-Tlt-tlL J6l~(iR ~ {~(L , ~ I (J2, S I ~ tJ..Ht--tf-e 1- 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 'l.' yJ: BELL JAR: INDICA TE IF THIS APPLlCA TION IS FOR A BELL JAR LICENSE YES 0 NO $-. 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 YES 0 NO fi- 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.4/0J) Page 2 of2 1I1111111111111111111~ 11111\ -.J