Wappinger Elks Lodge
I
GC-S
I
LICENSE TO CONDUCT
GAlVIESOFCHANCE
PLEASE CHECK
GAMES OF CHANCE IKl
BELL JAR 0
RAFFLE 0
GC-rn-~-GLLJ- ~
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: 1195 Rt. 376 City: Wapp i ngers Fa II s~ NY
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity. Patriotic. Youth Activities. Educational
Names of Members in Charge
Zip Code: 12590
Pau I Bader
Louis Antolotti
Simon Kaufman
Lew Hak im
LICENSE PERIOD
DATE
March 3. 2006
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
Fri day
7:00pm to 1:00am
BI ack jack
Joker Poker
Biq Six Wheel
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
$
I THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED I
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF GAMES
EACH GAME (Starting Bank)
NUMBER OF WHEELS
EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
February 10~ 2006
(Date)
TOWN CLERK
(Title of Authorized Officer)
L BJ-GC-S (Rev. 4/03)
Ci "__
p ~
(Signature elf Authorized Officer)
111'11'111'" 1111111"" 11111 ..J
'il(
~imuu 1'Knufmnu :J;( b - 57 31
iErun 1'Knufmnu
9 ~ ontl11IicUJ iianc
iljopcUJdl 4lulldioll, ));11 12533
PllY ill ~1e '~'rl Lu CL.
f
50-235/219 - CJ~9
561 u
-bG--, 'Db J-fJOp 2486
\
$ 'J-S h-j b--"
JOiate
{D ContainsSecunty
TnI, 11 11 Features,. Details
llJ'OlL1LBLn'S t on Back
THE BANK OF NEW YORK
ROUTE 82
HOPEWELfLJUNCT~ION' NY 12533 ~ _-L~~
' , --", -L' ,I ,'" -
[1m- __ ,c_l2Jl~ 1 , J I _ __ ~y~__-,!
I: 0 2 . q 0 2 ~ 5 21: 1110 2 ? ~ . 0 ~ b 5 ~ III / 2 ~ 8 b '
{lCHECK GALLERY 1995 STYLE # P03 1-800-354-3540 www.checkgallery_com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
...A
~
~
~
~
~
~
A,"', r'\
(~':O ~
'.> .,:? .z.
r<' A'\
\~,' \A
'~ '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
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC - [ill] -lliIIJ - @E0 - ~
N.Y.S. Identification Number
/00/./ tJr tJ~/~/Alc.E'~
Name of Municipality
/1tIC-U~
I
// ?.5
Address
Lf. 37t
1J/f~/'/#F&"e5 rALL S' #v
" /
/,1 S 9'iJ
I
After investigation, and a hearing if required under Sec. 192 of the General Municipal
have been made: .?;?
1. All the members-in-charge designated in the ap
character and have never been convicted of cri
Signature of Person Conducting Investigatio //
w, the following findings and determinations
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 La be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
Nj~
~
DNo
B"Yes DNo
[2f Yes DNo
cfYes DNo
~Yes DNo
E:( Yes DNo
O'Yes DNo
~Yes DNo
.EIYes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and terminations stated above, license is GRANTED~; license'
/ Signature of
Filing daLe of Application Authorized Officer
Date
,1 . /;; - t7 f;;
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) 1111111111111 111111111111 "" -.J
I
GC-4
NYS RACING & WAGERING BOARD
] WatervIiet Ave. Ext., Suite 2
Albany, NY ] 2206-1668
Telephone (5] 8) 453-8460 Fax (5]8) 453-8492
www.racing.stnte.ny.us
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
I
GC-0IJ-~-~-~
N.Y.S. Identification Number
'/0 ttJAI () r tJ/lIj>/AlC-F~
Name of Municipality
Du -r C#E5.5
County
// ?.5
Address
H. 37~
/J/f~/'/#t?&-L5 rAL.L$' A/V
./ /
/,t S 9'iJ
I
After investigation, and a hearing if required under Sec. 192 of the General Municipal aw, the following findings and determinations
have been made: /7 /'
1. All the members-in-charge designated in the aR
character and have never been convicted of cri
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 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)
111-
~
DNa
cf'Yes DNo
0Yes DNa
GYes DNa
r1 Yes DNa
r:(Yes DNa
Q'Yes DNa
IZf Y es DNa
ElYes DNa
DYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and terminations stated above, license is GRANTED ~; license'
Signature of
Filing date of Application Authorized Officer
Date
/J-(;;-C{;1
Title
t~
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) 1111111111 1111111111111111111 ..J
r"
GC-2
-,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (51 R) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE !Xl
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$US. t'tJ I
Fees Received
~/ICJfbl/~
Dale
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC-[ill]-~-~-~ RECEI
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLIC.~Wr{'
-("'~U 0 ~ w A Pp l v~t2... \)UTcl{~s LJ
Name of Municipality County r OWN CLERK
"
,/"
3. Has applicant ever been denied a games of chance license?
,
If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation 0
""'. State incorporated \ )~ 4..'> '\./ () R. \L
Incorporated Association po.. -""'~-t
_ Date ~o-l~ I / @JJJ / [ilTI
Date IT] / [IJ / IT]
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification nurr was assigned? 0 Yes )g(No
6. Are you doing business under a trade name? 0 Yes 0 No If "yes", what is the trade name?
PART B. LOCATION 01<' GAMES ...... .J
7. Address where games, bell jar. or raffle drawing(s) are 10 be conducted. JJ ~ ~ W.':, 7 ~ wAf> f: ~ \J: 1. .
8. Name and address of authorized games of
chance lessor renting to applicant.
~LA-
9. Does the applicant own the premises? ~cs
o No If "yes", how long?
d-~~
11. Have premises been regularly used? ~es 0 No If "yes", how long? ~A-~ 2.._
Are games of chance being played now on these premises or ha..<i it ever been? ~ Yes 0 NQ If "yes", give full details.
Q0e.'c'J-1 ;)..00S-
10. Capacity for public assembly of premises presently owned or occupied.
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", slate the type of license and number.
CL-oro:l!f-;).43
13. Has such license ever been If "yes". why? (Explain on a separate sheet, if necessary. and attach.)
revoked or suspended? 0 Yes ~o
L BJ-GC-2 (Rev. 4/03)
Page 10f2
1111111111 " 1I111111111111111 .J
r
I
P\,\RT C. PURPOSES OF GAMES
14. State the Specifi,.:;urposes.. for which the entire net proceeds are to be devo}ed and in what manner.
I (C~\~f;Ln 'J{~ OPr! RA-TlotJ
'-:?
I swear (or affirm):
I. That ALL the all ached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. Alllhe answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shull be devoted exclusi vely 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 !ind 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 oroinances 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, !lnd 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. exceptIO bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
~/lol~I/[QG
Date
gffhC'h ~ ~Y3NA/("
Print ame
STATE
::~~,;, }ss
, "';';~~f. J C<;:,J.
COUNTY
,+,.
"
('-c<:\ 'v
,:";.~d 'i.i :J~J ;;..-;-, "
l..,,:: ',",\/~'::;",.~ ~~i!;ri i)(J.':
()7
CITY rrOWNNILLAGE
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 affida viI.
'd (I~ (I n
fore me this day of}C,{)-
,20~
Signed _~ Q,0edJ2
O~m~
Commissioner of Deeds
My Commission expires
,20 n
L DJ -GC.2 (Rev, 4/03)
Page 2 of2
III I 1IIIIIIIIIIlnlll 11111 III .J
r
GC-2A
-,
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 -lli!Ji] - ~ - ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names. addresses and dates of binh of all officers.
If organization is a corporation. or an incorporated or unincorporated association, list officers and directors.
TITLE NAME J ~TE OF BIRTH STREET ADDRESS CITY
~SlZti. ~~~/_I_I I
I 1_1_1_1 I
I 1_1_1_1 1
I 1_1_1_1 1
1 1_1_1_1 I
I 1_1_1_1 I
, 1_1_1_1
, 1_1_1_1
1 1_1_1_1
1 1_1_1_1
I I I_L 1
- ~,-
Attach additional sheet if necessary.
MEMBERS IN CHKRGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHlP STREET ADDRESS CITY ZIP
auL \3A-0lii( I~I ~O I~q I-ll-l~ ~R~\.(.Qs R'\)~Jl-MJluli- l)-)LfD
LOtnS >>tvOL-01rII..JLI ll/~I--LL-1 h).~ RO{.bl\J(.()W L-tJl.~Pf. ~t..SllJ.-. ~ crO.
Se ~tt! K flu ~ tt _~JJJ~) kl ':i. 1-3 Sovr~ VI fiw l-rl-,-~f B-, I (J. I I ~ ,- '7 3-
L-TiW M:ttJ~) ~_I-2 1 .J;2 1 ~I 3 ~r tJ\}~ ~v ~ (,~ w /+( f. ~L!7 1 'r ),'1 0
I 1 1 I 1 I 1
1-1-1-1 1 1 I
1-1-1-1 1 1 I
'-1-1-1 1 I I
1=1=1=1 I 1 I
@U]/~/~
Date
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
IA TE GAMES OF CHANCE ID NUMBER
L BJ.GC.2A (Rev. 4/03)
Page ] of 2
1111111/1111111111111111111 --1
r SC~EDULE 4: ASSIST ANTS TO MEMBERS IN CHARGE OF GAMES
, List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
~~1 (}r(1k/lt1() Li!tL / _ / _ I _ 1 ,
I / / I_I I
-/-/-1_1 I
-/-/-1 I
,-/-/-, = I
,=/=/= - I
I / / _I
1-/-/-1 I
1-/-/-1=1
'-/-/-'_1
'-/-/-1_'
1-/- /- I
/-/-/- -I
/-/-/-1=1
1-/-/-1_1
-/- /- I
-/-/-1-1
'-/--/-1-1
1- /- /- I - i :
I_I
1-/-/-\ I.
-/-/-: - 1''*
1_.
-/-/-1 :,
_I
'-/-/-1_1
'-/-/-'_1
1-/-/-/_1
1-/-/-1_1
'-/-/-/_1
/-/-/-1_1
1-/-/-'-'
1-/-/-1 _I
,-/-/- I _ ,
,-/-/- 1 _ ,
,=/=/= , -
1_/_/_1-
L 8J.GC.2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY
I
ZIP
I
i
I
i
I
I_-
I
1
,
,
I
I
I
I
1
I
I
11111 ~IIIIIIIIIIIIII UIIII .J
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 Jct. 12533 09/15/1957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04125/1948
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 04124/1944
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.
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
WilliamK.
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
JuNano
Jurina
Minkowski PSVP
Pampa lone
Perretta
Sarno
Tucker
Wallner
DOB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack 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 Jct
Wappingers Falls
Highland
Wappinger Falls
Fishkill
Wappingers Falls
Wappingers Falls
Poughkeepsie
Wappingers Falls
Fishkill
Wappingers Falls
Hopewell Jct.
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
r ,.,
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Watervliel Ave. Ex!., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.slale.ny.us
I
GC- rn - [JIliJ - ~ - ~
NYS Identification Number
~/I?'lol/rn
Date
SCHEDULE 5 DA TES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
DATE
,~./,Q~ /~! ,
,- ,
HOURS
.:,7,oQun~- ~:.O ,0 ~pm !$,
. : , . am / pm - , : . . am / pm ! $ .
,', ,am/pm - ,', ,am/pm!$ ,
. , . am / pm - . , , ,am / pm ! $ .
, , .am / pm - , , am / pm ! $ .
,', ,am/pm - ,'. ,am/pm!$.
, , am / pm - , , am / pm ! $ ,
.', ,am/pm - .'. ,am/pm!$ '---'-
.', ,am/pm - ,', ,am/pm 1$ ,
,am / pm _:. , . am / pm ! $ ,
,am/pm~,.. ,', ,am/pm!$ ,
,am / pm ~. . , ' . , am / pm ! $ ,
RENT
.0 ",() ,0,
, / .
, /.
/.
, / ,
,/ ,
/.
, / ,
. /.
. f.
, f .
. f ,
DATE
. / .
, / ,
/.
, / ,
,/ ,
. / ,
. / .
. / .
/.
. / ,
. / .
RAFFLES
,-,
,-,
I
. .
I
. .
I
I
I
. ,
I
. ,
I
. I
I
,',
.1.
,-,
,',
"
,-,
,I,
,',
,I ,
,',
TIME PRIZES (Cash or Fair Market
VaI ue of Merchandise)
I am / pm - am / pm 1$,
. I . ,-, I- , . . . .
I am / pm - am / pm !$,
I , . . . . II . , ,-,
I am / pm - am / pm !$.
. I . ,', , II . . , '---'----0
I , am / pm - am / pm !$,
I , I', ,I, , ,',
I am / pm - am / pm !$.
I , . . . , o' , . --..l . .
/ . , f .
,/ , f ,
/, .f.
, / , . f ,
/. /
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
CLJlA-N\~G- t<1mH. 'R(Zl~f\UVZI2. .?-.c.<?'\J~~Qoo~t' l-klf/Z..JC-l' ~:'{ .
L-1<:!uO(\ LlCfZ.tJc;'/Z.- f~Il.>J~~l:\F!() Rv~~ llqD~'r~~ ~p,~~~
ZIP
p-S~~
\')~ 0
L BJ-GC.2B (Rev. 4/03)
Page 1 of2
1111111111111111 /I /111I111 ~ .J
~ .
r S~I;IEDULE 7 TYPES OF GAMES -,
. List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for V e~as Ni~hts and Bazaars onlv: 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)
~~t\LJ:t\-ttL
.IQ.t<~ ftl~(L
&1 {!.., S I'~ W ij-rV:t t.,..
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
,~'
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A 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 APPLICA nON
IS FOR A RAFFLE
LICENSE
YESD NO ~
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. 4/03)
Page 2 of2
IIIIIIIIIIIIIIIIIII~ 11111/ ..J
r
GC-2
I
NYS RACING & WAGERING BOARD
I Watervliet Ave. EXL, Suite 2
Albany, NY 12206-1668
Telephone (51 R) 45:1-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION }'OR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR D
RAFFLE D
I FOR OFFICE $1 ,15f vi!- ~7r~-I71/Tt~r cil
i USE ONLY .- ~ I
L Municipal License Number Fe,e,~_~~~~~_d__~__ Date :
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY R EC
Gc[illJ-~-~-~ _ EIVE
N.Y.S. Identification Number FER
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
--L 'Ot{) U . ~ r U) A P P l \J 64f.12.. \) uTe \-hz. S %\/1/1\ j (; I .L-A
NameofMuOlclpaltty, County .."..i--,I
.,
{..
3. Has applicant ever been denied a games of chance license? DYes
\
If "yes", why'! (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Cor'ponttio/l D
Incorporated Association
~
State incorporated 1Lt'lJ.~')
"1 () ~ \L
_ Date ~[J / rom / CillJ
Date IT] / rn / rn
Unincorporated Association D
State incorporated
Individual
D
5. Did your corporate status change since your identification nU~ber was assigned? D Yes ~NO
6. Are you cloing bllsine~s under a trade name? 0 Yes D No If "yes", what is the trade name?
PARTB. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted.lJ q S' ~ ~ 7 ~ UJ Af P. ~ \J :~ .
8. Name and addn:ss of autholized games of
chance lessor renting to applicant.
~/Jt
9. Does the appl1cunr own the premises')
-----....
J-rg ~
11. Have premises been regularly used? ~es D No If "yes", how long? l ~ i 1ZA-~ s,
Are games of chance being played now on these premises or ha<; it ever been? r)l Yes D No If "yes", give full details.
Q6e.' 0').1 :1-00 q
rf.;! es
o No If "yes", how long?
10. Capacity tor public assembly of premises presently owned or occupied.
12. Afe the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
tfl.-Yes D No
If "yes", slale the type of license and number.
cL .... ooo:I!t-~) Lf 3,
13. Has such license ever been If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
revoked or suspended? 0 Yes ~o
L BJ-GC-2 (Rev. 4/U3)
Page 1 of 2
1111111111" II" 1111111111111 .J
r
-,
PART C. PURPOSES OF GAMES
14. State the speCitt~;rposes for which the entire net proceeds are to be devo}ed and in what manner.
, (C~\~f;Ln 'J{~ ofCiR.A-TtOtJ
'-?
[ swear (or affirm):
I. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material pflrt hereof.
2. That the Cnlire net proceeds of all games of chance shall be devoted exclusi vely 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 presenl 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 oroinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary. compensation, reward or recompense will be paid to any person for holding or assisting in the operating or
conducting of the games. except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
~/loIO\I/@K]
Date
$~Ac~ F. j)kbPt~/.A (
Pnnt le
STATE
OF
NEW YORK
COUNTY
OF O()-tU~
OFJI)htLU
"J~j. '
}ss
':.;ji'!'i'SF. J. OF?"
P;JhL..:, :'i';'!:~~l c7
No. Q;;::.r~:"()2
r. '~;;;~d ~n D~h;;~~),~,
"'j..:~t-:,:';i\ fx.p~t,. UHC
.~
CITY rrOWNNILLAGE
J.'
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.
SWc:h;;::; j}t~~' 20&
~ry ublic
My Commission expires / J.-. - ~ , 20 ~
Signed -C t~r~ tJQ/ll IV'---
Commissioner of Deeds
L DJ-GC.2 (Rev. 4/03)
Page 20[2
III 1111111111111011111111111 .J
r,
GC-2A
-,
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
Name of Organization
GC- [l]- [wnJ - ~- ~
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. lisl officers and directors.
TITLE NAMEI~TE OF BIRTH STREET ADDRESS CITY
k:~fZ. ~ t;~1 _I _I I
1 1_1_1_1 I
I 1_1_1_1 I
\ 1_1_1_1 \
I 1_1_1_1 I
I 1_1_1_1 1
I 1_1_1_1
\ 1_1_1_1
1 1_1_1_1
\ 1_1_1_1
I 1_I_l-.-1
"4"
Attach additional sheet if necessary.
MEMffiERSINCHKRGEOFGAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
0}v L \3 A-oa~ I ~ 1 !)-O 1 ~~J -U- \ ~ ~\.}\) Rfi~ S R\) ~R}}.(\J\J I urzL- l)- ~'t 0
LCUlS ~~L.-O'1rll-k..1 U/~I-LL-\ ~q ~O-P.JI\)(.tlN /,..tJl\~Pf. ftH,t..S,llJ- S ((0
S[li"") :1/11 ttW --.-fL / .lie- / .2lL I '-/ I ~ SDVTid- ~ \..rl ,-~f e.. T (J. I I ~ 7 '7;;'
L--Ciw __ _)~ 1~/.J;;11 ~I '?:> ~ fJ\Jv:?~V ~L.~W/}-fP.~~71 1'1- ),'1 ()
I / 1 I I \ \
\-1-1-1 I I I
1-1-1-\ I I I
1-1-1-1 \ I I
1=1=1=1 I I I
@lJ]/~/@IfJ
Date
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER)
NAME OF A
ILIA TE
GAMES OF CHANCE ID NUMBER
IIIIIIIIIIIIIIIIIIII~ IIIIII1 ~
L BJ-GC-2A (Rev. 4/03)
Page I of 2
r ~CHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I
LiSl a1l members of appliclUlt organization and members of authoriz.ed affiliates and auxiliary who will assist with games. Each person listed mUSI he a
member of applicant orJl;DniUltion or affiliate for allellSl I year.
YEARS OF
MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS
B~1 ~V110 L-tiEL / _ / _ , _ I
I / / 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
I-/-/-! _I
1-/-/- _ I
1-/-/- I _ I
1-/--/-1- !
1-/-/-1_1:
1=/=/= I _ I'~'
I / / I_I
1-/-/-'_1
1-/-/-1_1
1-/-/-1_1
1-/-/--1_1
1-/-/-'_1
1--/-/- I _ 1
1-/-/- I _ I
1-/-/-1_1
1-/-/-'_1
1-/-/-1_1
1-/-/-1_1
,-/-/-, I
,=/=/= I = I
L 8J.GC-2A (Rev. 4/0J)
Attach additional sheet if necessary.
Page 2 of 2
CITY
ZIP
"" 11111111111 1111 III UIIII --1
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 05/02/1942
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
WilliamK.
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
Ju~ano
Jurina
Minkowski PSVP
Pampa lone
Perretta
Sarno
Tucker
Wallner
DaB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack 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 Jct.
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
r,
GC-2B APPLICA TION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
I Watervliet Ave. Ex!., Suite 2
Alhany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.lIs
I
GC-rn-~-~-~
NYS Identification Number
~/WQJ/[ill
Date
SCHEDULE 5 DA TES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
DATp:
~ I.a?;; /~!
. I .
, / .
I
. I .
. / ,
/.
, / ,
/.
, / .
, / .
/,
" .
HOURS
,:,7.()()lm(if)- ~:,O .0 c;Apm!$.
,am / pm - , , . am / pm ! $
,am / pm - , ' . . am / pm ! $ ,
am/pm - " .am/pm !$ ,
.am / pm - , . am / pm ! $ .
.am/pm - ,', ,am/pm!$.
.am / pm - , . am / pm I $ ,
.am/pm - '. am/pm! $ ~
.am/pm - ,', .am/pm!$ ,
am / pm ~:. , . am / pm I $ ,
,am /pm~J." " , ,am/pm! $ ,
,am / pm :. , . . , am / pm ! $ .
RENT
.0.,.(1 0,
, I .
. I .
I.
, I ,
, I ,
I
I,
, I .
I
I.
I
"
,I,
,I .
I
I
, .
I
I
I
I
I
, I
I
II ,
,I .
" ,
" .
" ,
" .
. ,
.' .
,I ,
RAFFLES
DATE
I . /
/ , / .
/ , , / .
, I , I ,
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 STATE
ClJ2i\.{v\ ~6- KffnH. 'KlZl1""3f\UVZf2. .?-~f\\;rz~Qoo~f' l+of/Z.- Jel. ~:'{ .
L,t <DuD t\ Llq~JJ'7~ f1+-~.>J [~.:A-l.1"lU) Rv~rZ" tl q s-g~~~ ~1J}-fP,~S~
TIME PRIZES (Cash or Fair Markel
Value of Merchandise)
I am / pm - am / pm !$.
. j . " . , . . ,. ,
I am / pm - am / pm !$.
. J . . . . I , ,. ,
I am / pm - am / pm !$,
. I . " , .' . . .~~
I am / pm - am / pm !$,
. I . ,,, " L , ,I,
I am / pm - am / pm !$.
I . ,10
ZIP
p-S~~
\ ')0 L)
L DJ.GC.2B (Rev. 4/03)
Page 1 of2
1111111111 ~ 11111111111111111 -1
r ~CJIEDULE 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 VelZas NilZhts and Bazaars onlv: 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)
~t~J~t1C
~(~ fO (~(L
,
~ C2- 51 ~ tJ-nt--fZ-{t l-
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
',.'
,;.
BELL JAR:
INDICA TE IF THIS APPLICA nON
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 FOR A RAFFLE
LICENSE
YESD NO ~
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 THA T A SlNGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ.GC.2B (Rev. 4/03)
Page 2 of2
111111/ 1111111111111111111111 --.J
..
January 4, 2006
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 Knights of Columbus,
#1646, 2 East Main Street, Wappingers Falls, who will be selling BELL JAR tickets
on their premises throughout the year 2006.
I would appreciate your review of the application and then would you please
complete the "Findings and Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
John C. Masterson
Town Clerk
Town of Wappinger
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
ROBERT l. VAlDATI
February 6,2006
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 "Wappinger
Elks Lodge", located in the Town of Wappinger, who will be conducting a
Vegas Night on March 3,2006.
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,
~. .
..... '6:,~" ~.~..~.
,'<. ..tt;.......,-,'"-..;j~
"".~._._,
John C. Masterson
Town Clerk