Wappingers Elks Lodge (3)
TOWN CLERK
Chris Masterson
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-5771 - Direct
(845) 298-1478 - Fax
TOWN SUPERVISOR
Christopher J. Colsey
TOWN BOARD
William H. Beale
Vincent Bettina
Ismay Czarniecki
Joseph P. Paoloni
Office of the Town Clerk
May 13,2010
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
Bell Jar License- 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.
Jo n C. Masterson
T wn Clerk
Town of Wappinger
JCM/cf
enc.
TOWN CLERK
Chris Masterson
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
WWW.TOWNOFWAPPINGER.US
(845) 297-4158 - Main
(845) 297-577] - Direct
(845) 298-1478 - Fax
TOWN SUPERVISOR
Christopher 1. Colsey
TOWN BOARD
William H. Beale
Vincent Bettina
lsmay Czarniecki
Joseph P. Paoloni
Office of the Town Clerk
May 5, 2010
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, N Y 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the "members in charge" of the Wappinger Elks
#2609, Route 376, Town of Wappinger, who will be selling BELL JAR Tickets on
their premises throughout the year 2010.
I would appreciate your review of the application. Please complete the "Findings
and Determination" form attached and return the completed application to my
office.
Thank you for your attention to this request and your prompt reply.
Yours truly,
9&~~
Town Clerk
Town of Wappinger
JeMlcf
r-
iA
NYS RACING & WAGERlNG BOARD
1 Watervliet Ave. Exl., Suite 2
Albany, NY 12206.1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.stale.ny.us
Check the type of program(s) you are applying for: ~ Bell Jars
Check appropriate box: 0 New 0 Update 0 Assisting Only
APPLICATION FOR
REGISTRATION AND
IDENTIFICATION NUMBER
I
o Casino Night
o Raffles
o Bingo
1. Name of applicant organization
Date of Application: ~ / ~ / C2.[g
2. Physical street address of organization (cannot be a PO Box):
1/9~ R/~ 37b
Street Address
3. Mailing Address if different than above (may be a PO Box):
w.t{/f/.my'-~ hIls l#f
City /
/2S-fo
Zip
jJ. () , 13 'I<. t.f 7
Street Address/PO Box
tJ1Jor ~t.~ MII.r
City
;t/y
State
/;;S7o
Zip
4. Municipality where the organization is physically located or where the organization meets:
CITY ,J.{iOWN) VILLAGE of ~~~~
(pLEASE CIRCLE ONE) Na e of M 'clpality
County in which the organization is located: ])" r (II; t!!::5 ..s
5. Date the applicant organization was formally Organized:~ / W:LJ / ~
Note: an organization must be in existence for a minimum of three years prior to applying for games of
chance and one year for bingo
b. Has Ii games of chance identification number ever been issued to the applicant organization? rs1 Yes 0 No
Ifyes,listtheID#:[2J!J - [&If] - c.:f0IJ - ~
7. Has a bingo identification number ever been issued to the applicant organization? 0 Yes 0 No
If yes, IisttheID#: [I] - rr=IJ - rr=IJ - o=o=IJ
8. Slate the type of the organization (religious, educational, veterans, etc.): IJFHE""ypL c::;vi ~ Il p Te~r r-f/'"I; tJ/-/)cj2. !) r- G 1<1
9. Has the applicant ever been known by another name? 0 Yes )'if No If yes, state name and address:
Name
Street Address
City
State
Zip
10. Is the organization incorporated? 0 Yes 0 No
11, Does the applicant have a governing body (Le. Board of Directors)? J'![ Y es 0 No
If yes, how many members are there in that governing body? 9
12. Slate current number of bona-fide members of the applicant ex.cluding the governing body:
.2'10
NOTE: A person must be a bona-fide member of the organization for a minimum of one year in order to be
, Involved In the conduct of licensed games of chance,
13. Please give time and address of regular membership meetings: /g-.t/ J ~ 7A~/lJ tIi4-y or ~ /?Jour?;
30' ,
7 -- Pm /Jr;l-I<-Id' .J7~ t{{-1pV'J~1~ ~./lY /.2..5<7/0
Time I Address' I
L BJ-IA (Rev. 4(03)
Page 1 of2
III ~ 1111111 Ifill/ill 1111 I III -1
r
14. Does the applicant organization own or lease its premise? (circle one) 0"~/. LEASE
15. Will the applicant organization conduct games of chance 0 Yes 0 No and/or bingo 0 Yes 0 No
on its own premises? RYes 0 No If not, list.the name and address of the premises to be used:
-,
Zip
Name
Street Address
City
State
liQIE: An organization is limited to the location where games of chancelbingo can be conducted.
Please review the games of chanceJbingo rules and regulations regarding authorized locations
available on our website at www.racln2.state.nv.us
16. Please list the name of the licensed games of chancelbingo supplier where the organization intends to purchasellease its equipment
from: )( J fr
~: This does not include raffie tickets.
A ITACH ONE COpy OF EACH OF THE FOLLOWING:
I - If incorporated: provide a copy of the articles of incorporation and by-laws;
If not incorporated: provide a copy of the constitution and by-laws;
2 - If the organization has a charter, please include a copy;
3 - Please provide a list of the names and addresses of the members of the governing body including titles.
I swear (or affirm) that the information and statements contained herein have been examined by me and to the best of my
knowledge and belief are true, correct and complete.
.Llp~~~
Head of the Organization Signat
eX4J..,SD
;=1 Lf5G/'j. 6. Eo YGIZ- - I2-LJ L,GR-
Head of the Organization Print
J34 ItNDe..EwS f2-b/j-D
1-i+(;/?-f}N(fGVILLG ~ "J.Y /;}-5L/D
Head of the Organization Home Mailing Address
('6"-lfSJ ;}.;;J-3 - 7 3d- ~.
Head of the Organization Home Phone Number
STATE OF NEW YORK }ss
COUNTY OF :Du-~cks"~
ClTYrrOWNIVILLAGE OF ~D~"'lu.~S ~ C-
being duly sworn deposes and says that (s)he is the person above named,
that (s)he bas read the foregoing statement and the answer therein noted, and that such answers are true and that (s)be has personally
affixed his (her) signature to this affidavit.
SwomlO bef~ "4 D day of Mb..Y
-#.-~
No r -
My Commission expires S-- ~ I '0
, 20 J..SL..
Signed
N;hw.>.k L..,~e:z.
-
Commissioner of Deeds
, 20
NHUCME LOfIIZ
NDIaIy N* ... d NIw 'all
10 0110607.12
CII....... ~ ~
Mv CommIIIIOn bpIIeI , 0
L B.J.IA <Rev. 4103)
Page 2 of2
1111111111111111111111 U II ~
-
--,
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR Jl[
RAFFLE 0
$1 $?" no I
Fees Received
,GC-2
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext.. Suite 2
Albany. NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453.8492
www.racing.state.ny.us
FOR OFFICE
USE ONLY
[ili] / [ill / rn
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC- [ZliJ - CiliJiJ. GGEJ- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
-;010'</ () f' 4f1lp/r"IYf*fl1- :Vl/'/eh.ess
Name of Municipality County
PART A. GENERAL
1. Name of Or anization
Wilt G-
2. Address /J 9.5- J?% .37' J"IP.~~k7l.- m/~ J ~y
3. Has applicant ever been denied a games of chance license? CI Yes ~o
/~S-9D
If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation [)
Incorporated Association IS State incorporated ;l/e W Yo A- /<:..
Unincorporated Association 0
State incorporated
Date~ / GIJ/ 1~lol
Date rn / rn / rn
Individual
o
S. Did yom corporate status change since your identification number was asSigned? CI Yes Ol,NO
6. Are you doing business under a trade name? 0 Yes ~o If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. /I If ~"" I(-rl.f" 31 {g WAr, ~€tL kr/1r.,j/! /J.J--tjp
8. Name and address of authorized games of
chance lessor renting to applicant.
J(ri
10. Capacity for public assembly of premises presently owned or occupied.
o No If "yes", how long? rJ( 1 V Il..S I
,
31/'0
.
9. Does the applicant own the premises? ~ Yes
11. Have premises been regularly used? ~ Yes [] No If "yes", how long? -< 7 ~ '
Are games of Ch~"8 played now on Ihese premises or has it ever been? lit Yes CI No IT "yes". give full details.
B.dJ~ d~ jOljj2S-'
V '
12. Are the premises or any part thereof J.
where games of chance are to be played ~ Yes
licensed by the State Liquor Authority?
If "yes", state the type of license and number.
ONo {Jtu.A>-~~ t!v.r:#C7Pt237
13. Has such license ever been 0 y
revoked or suspended? . es
~o
If "yes". why? (Explain on a separate sheet, if necessary, and attach.)
R T.r-r_"- (R"". 4/03)
Page 1 of 2
\lllll\ 11\\\1\\\111 1\ \111\11\ ..J
-
-,
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
C:AA1't.ry") Ilr~~ e... . I/o u-f-h . {Slv~A- 'Li:-oAJ,4 i.-
f / '
I swear (or affirm):
1. That AlL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
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.
operat<<l and conducted. who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. R8cing & Wagering
Board and local licensing ordinances or laws, wiU be present at all times, in charge and primarily responsible for the conduct of games.
4. That the undersigned wiJl 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 Board.
[D/[D/CD -cfpf'<~.fi .bJJ1
Date Signature of Head of Organizati
OF NEW YORK }
OF :Dt.l- .b, J, t. ~ S ss
crryrrOWNIVILLAGE OF Pe>uj "'~tff
6;' , e.. -e.n ~ e,~ . being duly sworn deposes and says that (s)he ~s the person above named,
that (s)he has read the foregoing s nt and the answer therein noted, and that such answers are true and that (s)he bas personally
affixed his (her) signature to this affidavit.
EtLE. G'fJ 730 ~GfL
Print Name .
STATE
COUNTY
swomw~~.pday: J:1~j_' 20
~bliC~
My Commission expires -1::1a...y ~ ,20 10
10
P.;...+
gi8lu~d
~~ "'~-<-
Lo~.e.. -z.-
Commissioner of Deeds
NHUCHE LCRZ
HOICIy N:*: .... d NlIw U
NO. 01L0607.12 .
.~In~
CcmrlIIIIOn ___ .10
L BJ-GC2 (Rev. 4/03)
Page 2 of2
11111111 Ilnl nil II 1111111 .J
,
r
GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext.. Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
fJ.c-
Name of Organization
G~-lLIZJ- ~- ~-~
NYS Identification Number
;CHEDULE 1: OmCERS AND DIRECTORS
.lit IlaIIIClS, addreaes ad dates of birth of all ofticea. .
r otpDizatlou is a corporation, or an incorporaled or unincorporated UIOCiatiClll, Iiat ofticen and directora.
TIlLE NAME DATEOFBIRTH S1REET ADDRESS CITY ZIP
f".I.1-t.ft2lgJ.wJ aLe,p e:; 3ov...x.1 ()/ / 02. / JIg "lfrieP7Jf /dI I ~viA~ /2;'10
~"- 'f:Ji/k. 7JfIW/Jj1. a.. ;e I...:::L/ lL/ .:/f:.1I.J. is." fY'I ~A~ ~ /~01
4' I _ _ i'. . I ~I it- a~"4- 17r 1.E.2../ ~/ 'r IL.1t' #~duIo'.l 1</ ~ ll-~,i._ .i!f //uY~
ke1il~~ /4,(-1111 MA,c,J< 1)'HlJr~LtY I 0 j' I .!.LI .:t:L 1a..,Fll.cr.d' "JlA/ I ~v!4/~,,~-,;e~y' /';).6tJ3
/ I 1"/ I:" j I j /'
f~l&iUlH-t !2.ok-r m .1M-4Ihl"/IA- ~ 1:.L J/::k1/6 VorUli)..<N 4<r'v.r 6Jf'Jj . /1/1/ /~ft'
tJelktll1.GrL"i fAn~::'L4-- S, K#lIrr1~ I 1;")" I .!2L.I ~ts=cf J.I/lj/~ k-~(J.E I ~(.: ;p14 /~/..5
7'(l..u, I~ IIiLrf- er.4I2-Kj'e (:1</ I..1.LI..1.i:-1 1L.1.3J I/.ele.u '/>J.; v~ I t{,r~.o?~Pfl, I/s NY )2.r1o
1124~ri.?~ I S1f:/A4?u g, CJII1I4IJ,';J. I.!..LI 2LI .C.t::..I17.fJ.St'Mr-~ /Id I..d/tl I t(/#~LYfJi'k .44~,~y /).-JYO
'1/2-fl~tee I <}{~f'H'e~ ~; .te~/1 I)J I..iLI ~)'"lll /d12.t;~eA.d -;;U;14'" kl ~1I9Aj~llPJ.s',;(.~V /;J..j,t'3
71LU' .r~ << I ~e<t'" V~L"'v'1e Ln_/ ~ / ...!tL I {oj mhki'll ~.I<~ ::::;~Ji &ty I 2-S'.;l3
L'/lJln~e.. I "1hn~J 12- 6Dj-BZ- -:r~--,,-I 2::i::-1 2.:t-1/JY.4d~.r AI IL ~Yi". qtY I ;)'Nf:)
, " Attach additional sheet if necessary.
~/GW/[ili]
Date
;CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MBMBBRS OF APPLICANT ORGANlZATlON)
DATE YEARS OF "
NAME . OF BIRTH MEMBERSHIP STREET ADDRESS
S'''flno if ~J%.+.Jt by 1 .l!:- I ~I 7 I. ? 5{/~1/'~ 1I"ev.J Lv.
t..e:w: oS 1-I.4KI:b. 1-lL I .J::L 1.1L1 X' I ].y Oilf!/t41 /};{IIF 4trAl~
G/L.atf oS HJ...j..I D I...!L I ..QL I .lL1 :31 1/3 Hrp.- I'/.N t7' "
IlJ.uL $,HG/'Z- 1.d...1 ').cJ I ~.s-I It. 1/)7' IIlIrJ/<'tfWS t?d
1---/---/---1 I
'---I ___I ___I 1
'---/---/---1 I
1---/ ___I ___I I
1---1 ___I ___I I
CITY ZIP
!~i:t~~f
14i4l'hft."l!,' 1 "r /2:!Yo
I I
I I
I I
I I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILlARJESlAFPILIATBS. BACH AUXlLlARY/APPILIATB USTBD MUST HA VB ITS OWN ID NUMBER.)
~ NAME OF AUXn.IARY/AFFILIATE GAMES OF CHANCE 10 NUMBER
BJ-GC-2A (Rev. 4103)
-
Page 1 of2
111111111111I11111111I1111 ~ -.J
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
Ust all members of applicant organization and members of authori2ed affiliates and auxiliary who will assist with pmes. Each person listed must be B
member of applicant ofKllllization or aff"iliatc for at least I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I 1 1 I_I
1=1=1= I _ I
1_1_1_1_1
1_1_1_1_1
I 1 1 I_I
1=1=1= I _ 1
I 1 1 I_I
1=1=1= I _ I
1_1_1_1_1
1_1_1_1_1
I 1 1 I_I
1-1-1-1_1
1-1-1-1_1
1=1=1= I _ I
I 1 1 I_I
1=1=1= I _ I
1_1_1_1_1
I 1 1 I_I
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_1
I 1 1 I_I
1-1-1-1_1
1=1=1= I _ I
I 1 1 '1_1
1=1=1= I _ I
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1- 1 1 I_I
1"=/=/= I - I
. .
L BJ-GC.2A (Rev. 4103)
Attach additional sheet if necessary.
Page 2 of 2
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CITY
ZIP
I
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1II1111~1I mill 11111 nil II -.J
-
-,
Q.C-2B
I/YS RACING & WAGERING BOARD
l WaterVliet Ave, EXL, Suite 2
&Jbany, NY 12206-1668
relephone (518) 453-8460 Fax (518) 453-8492
NWW.racjng.state.ny,us
APPLICATION FOR GAMES OF
CHANCE LICENSE
GC- [L[] - ~ - ffiiliJ - ~
NYS Identification Number
Qg/~/rn
Date
SCHEDULE 5
DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPUCABLE FOR BELL JAR. GAMES)
~/,
. /.
. /..
. / ,
,/ .
, / .
. / .
. / .
, / .
. / .
, /.
. / .
RAFFLES
DATE
~
0/
./
./
./
./
DAlE
0/ .
. /.
. /.
. /.
. / ,
0/ .
. /.
. / .
. /.
. /.
. / .
. /.
.am/pm
.am / pm
.am /pm
.am /pm
.am/pm
.am/pm
.am /pm
$.
$.
$.
$.
$.
$.
$.
.am/pm $.
.am/pm!$ .
.am/pm ! $ .
.am/pm ! $.
.am/pm! $.
.. .
HOURS
I . .am /pm -
. . . . . . . . . .
I am/pm - .
0 . . . . . . . .. .
I . ,am / pm -
. . .' . . I' .
I ,am /pm -
. . 0 .' . . . . .
I . ,am /pm -
. . , . . . . . . .
I . ,am /pm - .
, . , . . . . . . .
I . ,am /pm -
, . . . . . . . .
I .am /pm - .
. . . . . . .' .
I ,am / pm - .
. . . . . . . I' .
I .am /pm -
. . . . . . .' .
I am/pm - .
. . , . . . . . .. ..
I am /pm - .
. , . . . . . . . . .
TIME
RENT
. . .
. . .
.. .
. . .
. . .
. . .
. .
.1.
. . .
. . .
. . .
.!. .:. .am/pm-,
I am/pm -
. I . a' &. .-
I am/pm -
. I . .. . .. ..
.!. ... .am/pm - ,
I 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
.
.. ..
PRlZES (Cash or Fair Market
Value of Merchandise)
.am / pm ! $ . . . . . ... .
.am/pm !$. . . . . .'. ,
,am/pm !$ ,..
.am/pm !$. ...
.am/pm !$. 0.'
/
./
./
./
./
. . .
. . ..
.
.. .
. I..
STATE
ZIP
BJ-GC-2B (Rev. 4103)
-
Page 1 of2
1IIIIlln III~ 11111111111 ..J
r SCHEDULE 7 TYPES OF GAMES -,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve285 Ni2hts 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.
~({
UST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
UST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $
at $
at $
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NOLIMlT)
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
YESJ( NO D
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 D NO ft(
IF YES, UST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRlZES 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. 4103)
Page 2 of2
1I111111111111111111~ Imlll ..J
r
GC-4
NYS RACrNG & 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 nON
FOR GAMES OF CHANCE
LICENSE
GC - GLJ - GLTI - [iliLJ - ~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
unicipal Law, the following findings and detenninations
~es 0 No
l1q~ R~ 17~_ M~PFiRgars Falls. NY
Address
12590
After investigation. and a hearing if required under Sec. 192 of the General
have been made:
1. All the members-in-charge designated in the ap
character and have never been convicted of a ri
Signature of Person Conducting Investigation
f chance are of good moral
!fitJe
'S ~e.r l ~~
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)
~Yes DNo
~Yes DNo
~Yes DNo
IlO Yes DNo
Kl Yes DNo
ttJ Yes DNo
1&1 Yes DNo
10 Yes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED 0: license is DENIED 0
Signature of
Filing date of Application 0') /01) / 1 0 Authorized Officer
Date
Title Town Cr.~rk
(Municipal Licensing Authority)
ONE COPY OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ.GC4 (Rev. 4/03) 1111111111111111111\\1\ II \\1\ ..J
r
GC-5
--,
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
GC - rn - CiliGJ. [iliLJ. ~
N.Y.S. Identification Number
~'~~.
NYS RACING & WAGERING BOAIill
] Broadway Center. Suite 600
Schenectady, NY 12305-2553
Telephone (5]8) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
This License Must Be
Conspicuousl)' Displayed
During Conduct of Games
$1 25.00 , I
Amount of Fee Paid Lessor's License Number
Municipal License Number
The following organization:
Address: 1195 Rt. 376, City: Wappingers Falls, NY
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Zip Code: 12590
Names of Members in Charge
Simon Kaufman
Lewis Hakim
Greg Sarno
Paul Bader
LlCENSE PERIOD
DATE
2010
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
RAFFLE DRAWING
DATE
DRAWING TIME DRAWING LOCA TJON
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
$
NUMBER OF GAMES EACH GAME (Slartmg Bank)
ITHE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
IDEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
I SHALL EXCEED $500.
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH ~
ST A TE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by Town of WRppin~f'r
(Name of Municipality)
Town Clerk
(Title of Authorized Officer)
."\
(Signature of Authorized Officer)
1111 III 1I1I111I II II 1111 1111I1 .J
5/13/2010
(Date)
L BJ-G~-5 (Re,'. 3/06)