Wappingers Elks Lodge (2)
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher 1. Colsey
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 - Fax
TOWN BOARD
William H. Beale
Vincent Bettina
Ismay Czarniecki
Joseph P. Paoloni
Office of the Town Clerk
October 01, 2010
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject: Wappinger Elks Lodge 2609
Please find enclosed the corrected copy of the GC-5 for the Wappinger Elks Lodge
2609 for the year of2010. The original was sent to you September 17,2010, with the
wrong date of 10/10110. It should have read 10/01110.
Please feel free to contact my office at (845) 297-5771 if you have any further
questions.
'y,Cj~~6c
J~ C. Masterson
Town Clerk
Town of Wappinger
JCM/cf
enc.
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher 1. Colsey
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 ~ Fax
TOWN BOARD
William H. Beale
Vincent Bettina
Ismay Czamiecki
Joseph P. Paoloni
Office of the Town Clerk
October 01, 2010
Wappingers Elks Lodge 2609
1195 Rt 376
Wappingers Falls, NY 12590
Subject: Corrected GC-5
Please Imd enclosed the corrected copy of the GC-5 for the Wappinger Elks Lodge
2609 for the year of 2010. The original was sent to you with the wrong date of
10/10/10. It should have read 10/01/10.
Please feel free to contact my office at (845) 297-5771 if you have any further
questions.
J n C. Masterson
Town Clerk
Town of Wappinger
JCM/cf
enc.
r
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 1XI
BELL JAR 0
RAFFLE 0
GC - rn - GLJ]. G:LJJ. ~
N.Y.S. Identification Number
fi ..:~,~),;,~
l~ Ii. ~'; ..(+,~
(''''.'',''.~".'...'''.'' .4,. ,H,.,.,
, '~'~'.[~;:, '.\l: '.~~'.
.' "";"/'; of;;,." . 'il
" , '....r.,.,......"..." 1
",,, -,~~~~~5.;:. c"
NYS RACING & WAGERING BOARD
I Broadway Center. Suite 600
Schenectady, NY J 2305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
WW\\' .racing.state .ny. us
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 75 .00 II
Amount of Fee Paid Lessor's License Number
Address: 1195 Rt 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable + 2/3 OperatioTIR
Names of Members in Charge
Paul Bader
Zip Code: 12"igO
Simon K.<l11fm<>n
Lewis Hakim
Greg Sarno
LICENSE PERlOD
DATE
10/01/10
11/05/10
12/03/10
RAFFLE DRAWING
DATE
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
7:00pm-12:00 am
7:00am - 12:00 Pm
7:00am - 12:00 pm
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF GAMES
EACH GAME (Starting Bank)
NUMBER OF WHEELS
EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
GAMES SHALL BE PLAYED IN ACCORDANCE WITH ~,
ST ATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by Town of W.<l8t;ng~r
ame of Municipality)
Town
of Authorized Officer)
September 17. 2010
(Date)
(Signature of Authorized Officer)
11111111111111111111111111111 .J
L BJ-G~-5 (Re,'. 3/06)
IV
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher J. Colsey
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 - Fax
TOWN BOARD
William H. Beale
Vincent Bettina
Ismay Czamiecki
Joseph P. Pao\oni
Office of the Town Clerk
September 7, 2010
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 October 01,2010, November 05,2010 and December 03,2010.
I would appreciate your review of the "Members in Charge" listed on 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,
JCMlcf
Enc.
TOWN CLERK
Chris Masterson
TOWN SUPERVISOR
Christopher J. Colsey
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 - Fax.
TOWN BOARD
Wi lliam H. Beale
Vincent Bettina
Ismay Czamiecki
Joseph P. Paoloni
Office of the Town Clerk
September 17,2010
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject: Wappinger Elks Lodge 2609
Please fmd enclosed the GC-2, GC-2A, GC-2B, GC-4, and GC-5 for the Wappinger
Elks Lodge 2609 for the year of 2010.
n C. Masterson
wn Clerk
Town of Wappinger
JCM/cf
enc.
r
GC-2
I 0 0 ({) $1 '15..a9. I
Municipal License Number Fees Received
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
~~s~IQ~t~~-16Iol~l- ~
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
To lNN o~ LJ~/PltV~lf~ bu.TcHESS
Name of Municipality County
PART A. GENERAL
1. Name of Or . tion
p
I'--FOR OFFICE
. USE ONLY
APPLICATION FOR:
PLEASE CHECK J
GAMES OF CHANCE I!f
(Casino Nights. Bazaars, Carnivals)
BELL JAR 0
RAFFLE 0
(only raftles wI over $30,000 net profits in calendar year)
',"
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
[Q}I] / lo-'~ 11/1"'10 I ~-
Date
2.
3. Has applicant ever been denied a games of chance license? 0 Yes 0 No If "yes", why? (Attach extra sheet ifnecess~
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation 0 State incorporated tV E IJJ Y 0 ~ k
Incorporated Association ~ - I
Date ~ / [Q]JJ / ~
Date[I]/[I]/[I
Unincorporated Association 0
Individual 0
State incorporated
5. Did your corporate status change since your identification number was assigned? 0 Yes lirNo
6. Are you doing business under a trade name? 0 Yes ~ No If "yes", what is the trade name?
PART B. LOCA nON OF GAMES f a..:59
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. (195' RT 37 <a Wftfflj)6f;< ~ {/S N
8. Name and address of authorized games of
chance lessor renting to applicant
rv I A
9. Does the applicant own the premises? ~ Yes 0 No If "yes", how long? y Ii.>
10. Capacity for public assembly of premises presently owned or occupied. ~ 1?t;-
II. Have premises been regularly used? '" Yes 0 No If "yes", how long? (:) 3 I 'i elt R:5
Are games of chance being played now on these premises or has it ever been? ~ Yes 0 No If "yes", give full details.
/-. AS\ 'D.4TE- b- ~ - 0~O/ 0
12. Are the premises or any part thereof If "yes", state the type oflicense and nwnber.
where games of chance are to be played 12!--Yes 0 No
licensed by the State Liquor Authority?
13. Has such license ever been 0 If"yes", why? (Explain on a separate sheet, ifnecessary, and attach.)
revoked or suspended? Yes t!No
r
PART C. PURPOSES OF GAMES
14. State the speCifiC! oses for which the entire net proceeds are to be devote
C a.iT bLE + ~
and in what manner.
D E~471 0 vJ.s
I swear (or affinn):
I. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games 0
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 Garnes 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 ofthe Games o(Chance Licensing Law, the Rules and Regulations of the N. Y.S. Racing & Wagering Board and with the provision
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 Board.
[illt/ [!Z] / [",2Q ~ ~ ~ b,A~t1- ft.. Co / eF
Date Signature of Head of Organization Print Name
STATE
OF
NEW YORK
ss
COUNTY
OF
j)0~€:5S
LJ f'.(fJtJCo&~ f4/15
CITY rrOWNNILLAGE
OF
being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
"3 J ~
swom~remeili;s _n_ ___ day of ~, 20lQ.....
rull'lAI'" ~
Notary Public
My Commission expires HERNAN VELEZ , 20
Notary Pul:lIlc . State of New York
10 No. 01VE6101982
Qualified in Dutchess County
My Commission Expires November 24,2011
Signed
r
GC-2A
-
APPLICATION FOR GAMES OF CHANCE LICENSE
i>{"..~....,
~...
,.
\;0. . fC'U""U~'''' ~
NYS RACING & WAGERING BOARD
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (5]8) 395-5400 Fax (518) 347-]469
www.racing.state.ny.us
GC- [ill] - [2I1]j - 101 DI ~I- ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation. or an incorporated or unincorporated association, list officers and directors.
TITLE NAME _ \DATE OF BIRTH STREET ADDRESS
L. SeE '((fIACHe-b .511~E' J 1_1_1 I
I ~I_I_I_I 1
I 1_1___1_1 I
I 1_1___1___1 I
I 1___1_1___1 I
1 1___1___1___1 I
I '_1___1___' I
1 1___1_1___' I
I 1___1_1___' I
I 1_1___1___1 I
I '_1_1___1 I
Attach additional sheet if necessary.
[Q@/(A1]/lvI91
Date
CITY
ZIl
I
I
I
I
I-
I
I
I-
I
I
I
I
I-
I-
I
I-
I
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY Zl
PAl..C.L C3A bt?"R. I-.!LI ~I ~i I t../ 1/3'i A";ORew-s RD I L4CeAA.JCaf I~
.5'1#0,'.} kA-c-(f1t;1,J I ~/1!e1 W 7 I i S. 'VI€W L N II+t>,tIewe/(:!cll/Zf{'3
/-'&11, !-f,4!<"Yl I~I ~/l'ltf::iT ~ I~~ ~uee; ~t,v ~ILJ:Vt.fls II~
Co(\t:?c- SI"lMo 1-2-1-L1J.!1jJJ d.. %" 1___A'u___ IWAft.ffs' Ilz5t
I I II I I !
1-1-1-' I I
'-1-1-' I I
1-1-1-1 I 1
1=1='=' I I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2AUXlLIARIESIAFFILlATES. EACH AuxnJARY/AFFILIATE LISTED MUST HAVE ITS OWN IDNUMBER.)
NAME OF AUXlLIARY/AFFILIA TE
GAMES OF CHANCE ill NUMBER
SCHEDULE 1: OFFICERS and DIRECTORS
WAPPINGER ELKS LODGE #2609 for 2010-2011
TITLE NAME ADDRESS TOWN ZIP DOB
EXALED RULER EILEEN E. BOYER 134 Andrews Road LaGrangeville 12540 01-02-1943
LEADING KNIGHT VACANT
LOYAL KNIGHT PAUL BADER 134 Andrews Road LaGrangeville 12540 09-20-1965
LECTURING KNIGHT MARK 0 D'ANGELO 17 Forest Way Poughkeepsie 12603 08-03-1949
ESQUIRE MARK H FOX 28 Tiger Road Hopewell Jet. 12533 09-15-1957
CHAPLAIN CATHERINE ROHLING 54 Brothers Road Wappinger Falls 12590 04-22-1942
INNER GUARD VACANT
SECREYARY ROBERT M AQUANITA 10 Vorndran Driee Wappinger Falls 12590 05-25-1942
TREASURER VACANT
TILER SUSAN DORLER 21 Valley Road wappinger Falls 12590 03-29-1939
TRUSTEE JAMES BOYER 134 Andrews Road LaGrangeville 12540 11-28-1937
TRUSTEE ROCCO VALENTE 61 Fishkill Hook Road Hopewell Jet. 12533 06-06-1941
TRUSTEE ALEX CZARNIECKI 31 Helen Drive Wappinger Falls 12590 10-16-1941
TRUSTEE CHRIS LEAHY 17 Partners Trace Road Poughkeepsie 12603 03-16-1965
TRUSTEE VACANT
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least I year.
YEARS OF
MEMBER NAME DATE OF BIRTH y)HIP SlREET ADDRESS
L SeE 4lf4 C-.iffb .L 16 I
I / / I_I
,-/-/- I _ I
,-/-/- I _ I
1-/-/- I _ I
'-/-/-1_1
,-/-/- I _ I
,-/-/- I _ ,
1-/-'- I I
1-'-'- I = I
,-,-,- I _ I
,-,-,- I _ I
,-,-,- I _ I
1-'-'- I I
/-,-,- I = I
/-,-,- I _ I
/-,-,- , - I
,-,-,- I _ ,
,-,-,- I _ I
1-'-'- ! _ I
1-'-'- I _ I
/-,-,- I _ I
,-,-,- I _ I
1-/-'- I _ I
,-,-,- I _ I
/-,-,- I _ I
1='='= I _ I
I , , I I
/-,-,- I = I
,-/-/- I _ ,
,-,-,- I I
1='='= I = I
, , , I_I
1=/='= I _ I
CITY
ZI
I
,
1-
,
I
I-
I
,
I
,-
I
I
,-
I-
i
,-
I
I
!
'-
I
i-
I-
I-
I-
I
I
I-
I-
I
1-
I
I-
I
I
,-
I
I-
I
i=
I
I
I-
I
I-
I
i=
I-
i
!
'-
I
1-
i
I
i
,-
I-
1-
Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jet 11 0412411940
Philip A. Abbate 6 Hackensack Hghts Rd Wapplngers Falls 18 05/16/1937
..Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivlna 12 Thorns Lane Highland 22 12121/19~5
Henry J. Boldrln 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. Mlnkowski 427 McGrath Blvd. Fishkill 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sa rno 13 Dana Place Wapplngers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Klnry Road Poughkeepsie 19 01/17/1933
r
GC-2B APPLICA TION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.statc.ny.us
Gc-I (I~I- [2[illJ -I "I 01 ~I- ~
NYS Identification Number
Ivl rl / 131DI / [1lQJ
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
DA TE HOURS RENT
,1,0,1 :D:}!,.I ,O,! ,fJ1:,D.D ,am~ ,1j.,:,'O,~/pm !$,
,1.1./ 0 1./.0' ,DT:.D p~- .rd-:~pml$
,I .8. , / . D. 3, / ,J ,0 I . ~ ,/,:. D, 0 . p - J ,2.--:,0, c:xanD' pm I $ .
, / , / . , I, . ?Jf. : , ,am / pm - . . . .am / pm i $ .
, / , , / , ., , . , ,am / pm - , . , ,am / pm I $ .
, / , , / . I , . , .am / pm - . . , ,am / pm i $ ,
. / , . / , .. . . . ,am / pm - . . . .am / pm I $ ,
, / , . / , . I , , . . .am / pm - , . , ,am / pm I $ ,
. / . . / . ' . . . ,am / pm - , . . .am / pm : $ .
, / , . / . , . , ,am / pm - , . . ,am / pm I $ .
, / , . / . , . . . , ,am / pm - " , .am / pm I $ .
. / , . / , .. ,'. .am / pm - .'. .am / pm 1$ ,
.. .
,. .
.- .
.. .
I- .
.- .
.. .
I- .
,. .
I- .
,- .
.- .
RAFFLES PRIZES (Cash or Fair Mark(
DATE TIME
Value of Merchandise)
,/ /. am / pm - am / pm !$.
.. . .- . , ..~
. / , . / , am / pm - am /pm 1$.
.- . I- . . ..~
,/ . / am / pm - am / pm !$,
I- . .. . , . . ""'---'--
, / , . / , am / pm - am / pm !$,
.e . .- . . ..~
. / . . / . am / pm - am / pm !$.
.. . .. . . ..~
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY STATE ZIP
~i LVI,). O(J, Li c.etJGE fRsTEx. J1LT~D RLlIi:R 1'9:;- R!: .7 lCo LJPrff/~e!ft/4 ' z,~?u
(OOlJ UJ.<S L.o~Cot:=#alb09- /19~Qlc 37fc ~1f;AJ~p"d/s4 {-V590
I SCHEDULE 7 TYPES OF GAMES
List all ofthe single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Vee:as Nie: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)
i3LI\CJ< SAck
:) e Kef/.].. Po ~e1Z
G ; G 5tx Wf.lE~L
,
For Merchandise Wheels, Bell Jars and Raffies, 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 8..
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 APPLICA nON
IS FOR A RAFFLE
LICENSE
YESO NO ~
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES 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 MAYBE A WARDED IF SO
TNDIrA TFD TN ~rllFDT TT.F 4\
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 GAl\1ES OF CHANCE
LICENSE
GC - [iliJ - [L[LJ - GLLJ - ~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
11q~ Rt 17n W~ppingprQ ~~lJ~, NY 12590
Address
e General Municipal Law, the following findings and determinations
After investigation, and a hearing if req uired under Sec. 192
have been made:
I. All the members-in-charge designated in the
character and have never been convicted of
Signature of Person Conducting Investigatio
lIfyes 0 No
she~YI'~
Title
2. Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant are in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Games of Chance Licensing
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to he 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)
J6l Yes DNo
~Yes DNo
~Yes DNo
IX! Yes DNo
~Yes DNo
~Yes DNo
IX! Yes DNo
E!I Yes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED ~cense is DENIED D
Signature of
Filing date of Application September 7. 2010 Authorized Officer
Date
q \ "1-~ II ()
Title Town Cl erk
ONE COPY OF THIS FORM TOGETHER WITH ONE COPY OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ.GC4 (Rev. 4/03) 11111111111111111111111111111 .J
.-
1 .
.
r
GC-2A
-
APPLICATION FOR GAMES OF CHANCE LICENSE
.~
(t~hO.. ,_..." 7 \~. :
f" . _.:~~. "
.. ; ~ . .
'., .~ '.c~"" ~.1 .?
.. "\t-'I.-.1U\t. <.
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
GC- [ill] - ~ -101 D\ ~\- ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation. or an incorporated or unincorporated association, list officers and directors.
TITLE NAME;- ,\DATE OF BIRTH STREET ADDRESS
L SeE }8TACHtrf:> .5#~E~ 1 _I _I I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 1
I 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
I 1_1_1_' I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
Attach additional sheet if necessary.
[Q@ 1 [EG 1 10\91
Date
CITY
zn
(
\-
I-
I-
,-
I-
I
,-
,-
I
I
1=
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSIDP STREET ADDRESS CITY ZJ
PA\..tL BAbr~ I-LI ~I 19"~ 14 1/3<-f A~ORew~ ~D IL4C.eAAJ,=>f I~
.5, ffl o;..J J< ~LJ. f 1111 tJ 1 --.:L 1 .J.Je./ W 7 I J S. \) I € w L AI 1 1+ot'e0<?A { :S:clllZ6'3
J..Ew If. 11:;>.15., M 1__::1...../ n..IL'l'I::,T ~ I~~ ~l<ee: ~i"JL.fJ'~/p.f's II~
Coi\f:?(';p .$t1lWo I~I -LIJ.iJ!J ~ <a' '___A,u___ 1VJAf/J.fl5 11z,Sf:
I 1 1 I I I' I
1-/-/-1 I I I
1=1='=1 I I 1
1_/_/_1 I I I
1_/_/_1 I I I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXlUARIES/AFFILlATES. EACH AUXUlARY/AFFILlATE LISTED MUST HAVE iTS OWN ID NUMBER.)
NAME OF AUXILIARY/AFFILIATE
GAMES OF CHANCE ID NUMBER
SCHEDULE 1: OFFICERS and DIRECTORS
WAPPINGER ELKS LODGE #2609 for 2010-2011
TITLE NAME ADDRESS TOWN ZIP DOB
EXALED RULER EILEEN E. BOYER 134 Andrews Road LaGrangeville 12540 01-02-1943
LEADING KNIGHT VACANT
LOYAL KNIGHT PAUL BADER 134 Andrews Road LaGrangeville 12540 09-20-1965
LECTURING KNIGHT MARK 0 D'ANGELO 17 Forest Way Poughkeepsie 12603 08-03-1949
ESQUIRE MARK H FOX 28 Tiger Road Hopewell Jet. 12533 09-15-1957
CHAPLAIN CATHERINE ROHLING 54 Brothers Road Wappinger Falls 12590 04-22-1942
INNER GUARD VACANT
SECREYARY ROBERT M AQUANIT A 10 Vorndran Driee Wappinger Falls 12590 05-25-1942
TREASURER VACANT
TILER SUSAN DORLER 21 Valley Road wappinger Falls 12590 03-29-1939
TRUSTEE JAMES BOYER 134 Andrews Road LaGrangeville 12540 11-28-1937
TRUSTEE ROCCO VALENTE 61 Fishkill Hook Road Hopewell Jet. 12533 06-06-1941
TRUSTEE ALEX CZARNIECKI 31 Helen Drive Wappinger Falls 12590 10-16-1941
TRUSTEE CHRIS LEAHY 17 Partners Trace Road Poughkeepsie 12603 03-16-1965
TRUSTEE VACANT
.
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least I year.
YEARS OF
MEMBER NAME DATE OF BIRTH ME~)SHIP STREET ADDRESS
[Set: ,f-rf!lc.l+Eb i-ikT I
I / / ,_,
1-/-'- I _ I
,-/-,- I _ I
,-/-,- I _ ,
1-/-/-1_,
,-/-,- I _ I
,-/-,- I _ I
\-'-'-'_1
1-/-'- I _ I
1-/-/- I _ I
,-,-,- I _ I
1-/-'- I _ I
,-,-,- I _ I
/-/-,- I _ I
,-,-/-, - I
1-'-'- I _ ,
1-'-'- I _ I
,-,-,- I _ I
/-,-,- I _ I
1='='= I _ I
I / / I_I
/-,-/- I _ I
,-/-/- I _ I
,-/-/- I _ I
/-/-/- I _ I
1=/=/= I _ I
'-/-/_'_1
I , / I_I
,-,-,- I _ I
1-'-'- I _ I
,-/-/- I _ I
,=/=/= I _ I
1_'_'_1_1
CITY
ZI
I
I-
I-
I-
I-
I-
I
I
I-
I-
I-
I
I-
I-
I-
I-
1-
,-
I-
I
!
I-
i
'-
I-
I-
I-
I-
I-
I
,-
I-
I-
I-
I-
I-
I
i-
I-
I-
I-
1-
Schedule 4. Assistants to Members in Charge of Games
Years
~ First MI Last Name Address Town Elk DOB
~rank Abato 39 Kensington Drive Hopewell Jct 11 0412411940
'%hlllP A. Abbate 6 Hackensack Hghts Rd Wapplngers Falls 18 05/16/1937
Jgobert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
i'PhJ. Anzlvlna 12 Thorns Lane Highland 22 12121/19~5
. enry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
arold A. Crawford Sr. 318 Sunset Hill East Fishkill 18 02/23/1936 i
~anCiS J. DeGano 27 Brandy Lane Wappingers Falls 18 07/18/1946
oger DeJordy 83 Kent Road Wappingers Falls 18 09/19/1944 ~~i ~
. Robert Fischetti 91 Ardmore Drive Wappingers Falls 28 06/07/1926 ~ ~ -:'1
z,ark H. Fox 28 Tiger Road Hopewell Jct. 14 09/15/1957 Wtn$
~arriS C. Jones 217 Brothers Road Stormville 18 04/24/1944 ~~~~ ~
~bert J. Juliano 2776 West Main Street Wappingers Falls 13 10/05/1953 -~~~
~uS'
iIIiam ~. Mlnkowski 427 McGrath Blvd. Fishklll 28 03/20/1942 <-
8::t:~
Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943 r.n::t:
osemane .l;2:.t:
regory F. Sarno 13 Dana Place Wapplngers Falls 28 07/01/1936 o::t:
;z:O
~enneth J. Tucker 34 Pawling Lake Pawling 9 05
o~o..
obert N. Wallner 7 Klnry Road Poughkeepsie 19 01;17/1933
.
r
Susan G. Havelka
Joseph P. Havelka
38 Hickory Ln
Pawling, NY 12564
845-855-3731
~~a.- ;
~r~~~JY- n)l~~
~tLtL~\J/~ .
I: 0 2 ~ 11 0 b 11 3 ~ I: 3 2 3 280 0 ~ ~ ~ ~ 11111 20 2 b
F/~
2026
:eo I'D
50-693/219
$ 7S. bO
~~6J
Pawling, New York 12564
1-800-KEY2YOU Key.com
StOJ<