Wappingers Elks Lodge (4)
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
lsmay Czamiecki
Joseph P. Paoloni
Office of the Town Clerk
February 17, 2010
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
Games of Chance License- Wappinger Elks Lodge 2609
Please imd enclosed the GC-2, GC-2A, GC-2B, GC-4, and GC-5 for the Wappinger
Elks Lodge 2609 for the year of 2010.
ohn C. Masterson
own Clerk
Town of Wappinger
JCMlcf
enc.
I
GC-5
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 60{)
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
wWYI.racing.state.ny. us
--,
GC - G:LJ - GCIJ- ~-
N.Y.S.ldentification Number
$1 75 . 00 II
Amount of Fee Paid Lessor's License Number
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE ID
BELL JAR 0
RAFFLE 0
~
This License Must Be
Conspicuously Displayed
During Conduct of Games
Address: 1195 Route 376 City: tJ"ppinB"''''9 li'il'll<
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable. 2/3 Ouerations
Names of Members in Charge
Paul Bader
Zip Code: 12590
Simon Kaufman
Lpw;~ HRkin
Greg Sarno
LICENSE PERlOD
DATE
03/05/10
04/02/10
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
0'1/07/10
RAFFLE DRAWING
DATE
DRAWING TIME DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at FaIT Market Value)
THE MAXIMUM AMOUNT OF PRlZES 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)
EACH WHEEL
NUMBER OF WHEELS
ITHE 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 ~I
ST A TE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by Wappinger
(Name of Municipality)
"'n~r" r1 ~,...1r
(Title of Authorized Officer)
02/17/10
(Date)
. '..-
(Signature of Authorized Officer)
\\\1\1111\ 1\I11\1 \1111 I 1111\ .J
L BJ-G~-5 (Re,'. 3/06)
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 nON
FOR GAMES OF CHANCE
LICENSE
GC - [ili] - 0lTI - [Iili] - [Q]LIQ]lIJ
N.Y.S. Identification Number
Town nf W~pp~ngar
Name of Municipality
1195 Rt. 376. Wapuin~erR FAllR. NY 12~qO
Address .
nicipal Law, the following findings and detenninations
~s
ONo
After investigation, and n hearing if required under Sec. 192 of
have been made:
I. All the members-in-charge designated in the a IC
character and have never been convicted of cri
Signature of Person Conducting Investigation'
2. Applicant is n 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 owm:d 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 Garnes 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)
:iJ Yes DNo
:tJ Yes DNo
~Yes ONo
~Yes DNo
~Yes DNo
~Yes DNo
KJ Yes DNo
ltJ Yes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: ;'
As a result of the findings and determinations stated above, license is GRANTED Ei'license is DENIED 0
Signature of /l
Filing date of Application ? lOR I 1 0 Authorized Officer
J.J (;
Date ~I 10 Title Town 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.
LBJ-GC~(Ro,.4103) RIIIIIIWIWIIRI ~
I'
GC-2
I
NYS RACING & WAGERING BOARD
I Walervliet Ave. Ex!., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.slate.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE"
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 75 00 I rn/~/rn
Fees Received Date
INSTRUCTIONS: PLEASE Fn..E THREE SIGNED COPIES WITH MUNICIPALITY
GC - cz.li] - [JJJJI]- [f[QQ;l- ~
N. Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
tOWN of WA-fJr'IIVG-6~ J)ulclfE-SS
Name of Municipality County
2.
3. Has applicant ever been denied a games of chance license?
4. Check type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
Incorporated Association ii1 State incorporated N E.. w Yo R f<
Unincorporated Association 0
State incorporated
Dnte ~ / CQIZJ / ~
Dnte [[] / [[] / rn
Individual
o
5. Did your corporate status change since your identification IlU3ber was assigned? 0 Yes t1( No
~ No If "yes". what is the trade name?
6. Are you doing business under a trade name? 0 Yes
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted.
N/A
,
117S- 1'21-. 376 u/rf'NJ(jtfJ hill AlY 12J9~
8. Nnme nnd address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises'! . Yes 0 No If "yes", how long'!
2- 8"6
11. Have premises been regularly used? lit Yes 0 No If "yes", how long? 2- '3 V GAtE> S
Are games of chance being ylayed now on these premises or has it ever been?J[ Yes 0 NIIf "yes", give full details.
LASf D/rf6' F eb!?r.lA-t2.1I S-- 2.0/0
/ '
If "yes", slate the type of license and number.
btYes DNo C L - 000 712-43
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?
13. Has such license ever been
revoked or suspended? 0 Yes
~NO
If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
L BJ-GC-2 (Kev. 4/03)
Page I of2
11111111111111111111111111111 .J
r
-,
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the eftire net proceeds are to be devoted and in what ranner.
1/3 ChA~f+A- b / G + 2../3 O.,oF-/lA-TloIlJ
/ I
I swear (or affinu):
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 ofthe "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 tenus ofthe license,
the provisions ofthe 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.
[Qlil/IDI8'I/[2IQ] f? ~ --A/ix I? CUIfNW-k,
Date Signature fHead of 'ganization Print Name
'7'"~IIJT~ CilA,./lI'^"'J,)
OF NEW YORK
V <J+C~f3.SS
. O~ WArtINJE~
A \ ex P C ~r(\leLtCJ 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.
COUNTY
OF
ss
STATE
rjJJJ!17TOWN!..... ~X1
Signed A k:..)( f C -;z...q f AI k: c. t...:
Commissioner of Deeds
o Public
My Commission expires ~ (I 0 :L-
,20~
SANDRA E GRASSY
Notary Public. Stat. of N.w York
NO.01GR6192375
Quallfi.d In Dutchess Cou
My Commission Explr.s 0
L BJ-GC-2 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 ..J
'r
GC-2A
APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.stale.ny.us
-,
.~~
t.[t~!(';;;''".l~. ~1.'.;~:'
"~;~'~ I
..- ,,~<~-,-,.~,..,- ,,""
.~> ~'\ L..~.. "'l~.NL ' ~~'
[QliJ/[QJ1]/[illJ
Date
~-lu~JJ~l:I-lbI6121-~
SCHEDULE 1: OmCERS AND DIRECTORS
Ust names, addresses and dates of birth of all officers.
If organizaliOIJ is a <:orpondion, or an ............ated or uniucoIpulMled 8lI!IlKliIIliau list offic:eIs and directors.
111J:~ i N~ I i '\ DATE OF BJRTH STREET ADDRESS
-1J65 147tlK,bitLlb<<U)I_I_I_1 I
L 1_1_1_1 I
1 1_/_1_1 I
1 1_/_1_1 1
I 1_/_1_1 1
I 1_1_1_1 I
I 1_/_1_1 1
I 1_/_1_1 I
I 1_/_1_1 I
I 1_1_1_1 I
1 1_/_1_1 I
Attach additional sheet ifnecessary.
CITY
ZIP
SCHEHULE 2: MEMBERS IN CHARGE OF GAMES
(MUST I JST AT LEAST FOUR MEMBERS 01' APPLICANT ORGANIZATION)
DATE YEARS OF
1\ r~~fE f _ _ OF BIRTH MEMRERSffi.. P STREE~ ADDRESS)
~ ~I 20 II'US1 /1 I /34 A~~fj.VJJ ~_.
J;",Q/J /<A"fO'..rJ ----RI-&. I lmi. 7 i~~ ~;~~~~
L~vJlI I4A ~ 11'1'\ -:J-I -HI Mt 6: f._ _ ~ fj./I! _ ~L_'-;J
&~fiJ ~S4JtAlO -1- ~ -L ~ 1jJ(j 2& J f.
-,-,-\
-'-1-\
-,-,-:
=I=I=!
~",.--~
ZiP
Ju40
} 2S-33
J 1.. J9~
I zr'ltJ
s{'",,'m II.F. :\~ ;\UXfLlARY/AIl'fl'IUATR ORGANIZ-ATIONS ASSISTING AT GAMES
(.r.:1.A;XHvlUr~'t OF:2 AUXTI.JARIE3!i\FFiLIt\TES. EAJ~H AUXTLIARY/AFFlLIATF: LISTEn~iUST HAVE rr~ O\..,N ID NU;vffffJ-t.)
NAME OF AUXILlARY/AFFILLt\.TE
GAMES OF CHANCE ID NUMBER
LBJ-GC.2A (Rev. 3i(6)
Page lof2
11111111111 .J
I
I
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the eftire net proceeds are to be devoted and in what ranner.
1/3 Ct..Ate,+AIo It; + 2/3 O.4F-Il/tf/o;JJ
I I
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,
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 ofthe license,
the provisions ofthe 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.
[QliJ / [MI / [2JQJ f? a..~ -A lie I? CZ-AtftJ,tick,
Date Signature fHead of 'ganization Print Name
"T~ IIJTC CIII\,It.jt\"'jJ
OF NEW YORK
V cJ+c~G-SS
. O~ WArtlNJEI<
A \ ex P C ZfLrnJeLKJ 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.
COUNTY
OF
ss
STATE
rJ/I!/7TOWNf ~ _f"P
20~
Signed AJ<J( f C "J,..{Lr'" f~G t.:
Commissioner of Deeds
o ary Public
My Commission expires ~ / (') :l-
r
,20~
IMDM E wtAIIY
.., PuIIIIc . ... " New YOItl
110.0''''92375
QtIIIIIId III Dutc..... C
Mr CommIIIioIt ExpIre. 0
L BJ-GC-2 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 .J
I
GC-2B APPLICATION li'OR GAMES OF.
NYS KACING &. WAf/ERIN<J BOAIW CHANCE LICENSE
I WUlcr\'liel Al'e, Exl., Suile 2
i\lh,lII}, NY 12206..lo611
Tdcphollc (51 H) 453-114()() Fu~ (SIll) 45.~~WJ2
www.fiI..:illg.slllle.IlY.us
I
Name of Organil.Ulion
GC- [ill] - [1JL@] - ~ -10121011 ksl
NYS ldentilication Number
16 f21 / [0]1J / [ill]
Da[e
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(lVOT APPLICABLE FOR BELL JAR GAMES)
DATE · HOURS RENT
03 / OS- / I 0 ,{j 7 .:~QJI/II/pm .. . 1.2.,:, O. O,um/_!$.
o " /. O. 2. / J 0 ,0. 7.: 0 0 ._1 pm.. J 2.: 0 0 am/pIt'! $
.J2S- / JLl/ ...IJ2i 0.7 0.0 .~/pm - J. 2:.0.0 am/a!$,
/ / ,am/pm .. ,", .am/pm!$
~.~ / . . / . " am / pm .. am / pm ! $
~~...._.J / ~__~ / .__~._..' ~_~_......: ~---..am / pm .. . . am / pm I $ .
__0 / _~ / .' am /pm .. am / pm i $ "-----"- .
~~ I . / . ~-,. am/pm.. am/pm!$
~~ / ~_~~ / ~~~' ~____~: _________am / pm .. . . ,am / pm : $ I
_~ / / _~ I am/pm ..," am/pm :$
/ / am/pm '~'. .am/pm !$
=--= /' / '----"-", ::~~am/pm ~~~~:' am/pm i$
, . \-------~
. . -------'
RAFFLES
.am / pm
,am I pm
.am / pm
.am I pm
am I pm
PRIZES (Cash or Fair Markc;:[
Value of Merchandise)
!$,
1$,
:$.
!$.
!$
DATE
--- / / ~._~._---.
~~/ -~/ ".~~"
/ / I :
_-----..... _.,4;. ..__---'
/ . / ~---,---,: ~-_......:.
/ / :
. I~_~..
TIME
am / pm -
. .
am / pm ..
am / pm -
,am/pm -
,am /pm --
,-,
".
,- .
,"
SCHE1HJLE 6 EXPENSES
LIst items of expense to be incurred, and the names and addresses of persons LO be paid.
ITEM UF EXPENSE' VENDOR NAME STREET ADDRESS CITY STATE
'-Ilvo"'. L,c.aN.r~ fAst ~xJ,~1+6c;J RvlGfl II9S" 1<+,37 ( I)/tf,~c;trJ l/I.J N V
POQ J 13/J<J Lo..JJ6 ;Ji 260? 11 CJS' 121, 37 t Wtf''1MJ hll) tJ Y
ZIP
/1-S-90
I '2.. S9 ()
L IIJ-l;C.26IRev. 4/0.\1
Pag~ I 01':2
111111/111111111111111111111 .J
r SCHEDULE 7 TYPES OF GAMES I
List all ofthe single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve288 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.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
(3L A Ck "TPrCk
"JO I( G f<. ,001< E{C
~ if, SiX w /fEE L
For Merchandise Wheels, Bell Jars and Raftles, 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 APPLICA nON
IS FOR A BELL JAR
LICENSE
YESO NO.O
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
YESO NO 0
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. 3106)
Page 2 of2
I~IIIIIIIII HIllin III .J
..'
Schedule 1: Officers and Directors
~0t>'1 ~ ~l~
WAPPINGER LODGE #2609 OFFICERS for 211- In9).
Title
Name
-----..-------..------- --------------- -----------------------..-. -----------.-----.....-...-----
Address
Exalted Ruler
Leading Kgn
LoyalKgn
Lect. Kgn.
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
Trustee
Trustee
Trustee
Trustee
Trustee
Joseph P. Havelka Sr.
Eileen E. Boyer
Diana Cole
Paul Bader
Mark H. Fox
Catherine Rohling
Rosemarie Perretta
Robert M. Acquanlta
Pamela S. Kultsar
Susan Dorler
James Boyer
Rocco Valente
Alex Czarnleckl
Alfred DeRose
Vacant
38 Hickory Lane
134 Andrews Road
P.O. Box 549
. 134 Andrew~ Road
28 Tiger Road
54 Brothers Road
35 Cathy Road
10 Vorndran Dr.
58 Hillis Terrace
21 Valley Road
134 Andrews Road
61 Flshklll Hook Rd.
31 Hele,n Drive
25 Hickory Lane
No Officer receives compensation of any kind.
Town Zip DOB
--.---.--..-.---.-.-..-.---.--- -------..-- ---.----------------
Pawling 12564 11/13/1942
LagrangevlJle 12540 01102/1943
Hughsonvllle 12537 04/25/1948
Lagrangevllle 12540 09/20/1965
Hopewell Jct. 12533 09/15/1957
Wappinger Falls 12590 04/22/1940
Poughkeepsie 12603 08/07/1943
Wappinger Falls 12590 OS/25/1942
Poughkeepsie 12603 02/0111950
Wappinger Falls 12590 03/29/1939
Lagrangevllle 12540 11/28/1937
Hopewell Jet. 12533 06/06/1941
Wappinger Falls 12590 10/16/1941
Pawling 12564 11/28/1961
. 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
~MBER NAME DATE OF BIRTH MEMBERSHI.P {TREET ADDRESS
~ 8 c ;tiT) ft/ (J1/E D 1-.l:f. -r ;;I-
1_'_'_1_1
I , , I_I
1-'-'-1 1
1-'-'-1-\
1-'-'-1-1
1-'-'-1 = I
1 '1'1 . 1 1
1-'-'-1 = I
1-'-'-1_1
I '11 '1_1
1-'-'-1 I
III '1-\
1-'-'-1-1
1-'-'- 1= 1
I '11 '1_1
1-'-'-1 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
I '11 . I I
1-'-'-1 = 1
1-'-'-1_1
I '11 '1_1
\-'-'-1_1
1 '11 '1_1
1-'-'-1_1
1='='= I _ I
L BJ-GC-2A (Rev. 3106)
Attach additional sheet if necessary.
Page 2 of2
CITY
-,
ZIP
IIII1III1II .J
Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jct 11 04/24/1940
Philip A. Abbate 6 Hackensack Hghts Rd Wappingers Falls 18 05/16/1937
Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivina 12 Thorns Lane Highland 22 12121/19~5
Henry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936 .
Harold A. Crawford Sr. 318 Sunset Hili 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 Jct. 14 09/15/1957
Harris C. . Jones 217 Brothers Road Stormville 18 04/24/1944
Robert J. Juliano 2776 West Main Street Wappingers Falls 13 10/05/1953
William K. Minkowski 427 McGrath Blvd. Fishkill 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Piace Wappingers 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 APPLICATION "'OR GAMES O"~
t\iyS KAClNG & WA(iEI{INCi BOAIW CHANCE LICENSE
I WUI~..\'liel .'\ve. Exl.. Slllle:2
Alh<tll). NY 122llO-lotll!
Tdcphlllll.' ci IH) 45~~-1l4()O hl~ (5111) 45.\ ~W)l
www.raC:lIlg.slllle.lly.lIs
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Name uf OrgallJl.ulJoll
GC- [ill] - [1IL@] - [ilQill-1 012101//31
NY S ldcntilical10n Number
161zJ / 10 r7'l / ID f(j'j
Dale
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE Hf~LD
(lVOT A PPLlCABLE FOR BELL JAR GAMES)
DATE ' HOURS
03 / OS'I. I 0 ,6. 7.:~Ql,./pm - ./.2..:.0 O,um/.-I$.
o L/ /. 0 2. / . I 0 ,0. 7.: (j 0,8"1 pm - J 2: 0 0 am /jIiII( i $
.J2~~ / ..Q...7 / ~L.J2: 0 7 0 (') ,-/pm, J 2:.0.0 ,am;1iI.! $ .
/ 1 am/pm, am/pm '$ ~
~~~ / . 1 ~~ am/pm - am/pm :$
~~ __.~ / __~ / ',_ '. . . ~.__~___,' ~_______ am I pm - am I pm 1$ ., . ,._
__. / ~~ / __ ~~ am / pm - am I pm : $ '--------~~_'___'. ~'_____~
J / ~-,' am/pm - am/pllI.$ _.
___ / .____ 1 ~_~~ ~___~ : ~..______' am I pm . . . .am / pm '$ . ~~
__~ / 1 am/ pm _:' am / pm $ ._~
____~ / / '----J . . .am / pm 'j : . . . .am " pm : $ .
I / :'----'-~am/pm - ~~.:. am/pm:$
RENT
--...- .
RAFFU~S
DATE
am / pm -
am I pm ..
um / pm ..
run I pm -
am /pm ..
.am I pm
am I pm
am / pili
,am 1 pm
,am I pm
PRIZES (Cash or Fair Markc:[
Value ot' Mercha.ndise)
!$.
'$.
'$
, .
:$. . ,
!$
TIME
~---- / ~- / ~ -~._- -
.____ I __~ / , .~_~'.
/ ~~/ -~:._-~:
I I ~~! ~..___.
/ ,I.
,- .
'.
. ---+-------' . ~
SCHEDULE 6 EXPENSES
LJSI Hems of expense lO be incurred, and the names and addresses of persons to be paid.
ITEM OF LXP.l:::NSE' VENDOR NAME STREET ADDRESS C1TY STATE
tlll/C~ L'<.fJNS~ fAJ+ bxh.'t/f6,J Rvl(j!l 1''1~- {(i, '37 (; I)Itf'~j(jtfJ ~/& NY
Foe J /3/kJ LoJtr; :Ji 260Cj II 15' 12f,37t Wtf"";'''i4J nib tJ Y
ZIP
I t.s-9o
I L Syo
L IIJ-l;C.2lJ d(rt. 410.11
Pag~ I vf:1
1111111 IIII ~ IIIIII~IIIIIII -.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 Vee:as Niehts 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)
I31-ACk -rACk
JO /< E (( ,001< E/C
f!:,)6 SiX wHEEL
For Merchandise Wheels, Bell Jars and Ratlles, 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
YESO NO 0
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
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULES
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. 3106)
Page 2 of2
11111111110111 .J
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GC-2
I
NYS RACING & WAGERING BOARD
1 Walervlier Ave. Ext., Suile 2
Albany, NY 12206-1668
Telephone (5 J 8) 453-8460 Fax (518) 453.8492
www.racing.slale.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCEj(
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
Municipal License Number
$1 I OJ 1m TCOl
Fees Received Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - [ID] - rJILII]- ~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
tOWN of wA-ff/NG-6~ 7)ulcJ+ESS
Name of Municipality County
2.
3.
4. Check lype of organization and. if applicable, give the Stale and date of incorporation.
Corporation 0
Incorporated Association ~ State incorporated N E- !AI Yo R {(
Unincorporated Association 0
State incorporated
Date I O~ / [QJJ] / [&Z]
Date IT] / IT] / rn
Individual
o
5. Did your corporate slatuS change since your identification nu~ber was assigned? D Yes ~ Nu
6. Are you tloing business under a trade name? 0 Yes . 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.
N/A
,
1175"" /21. 376 uJ1r/~lit1J hll, IVy /zS9tJ
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? . Yes 0 No If "yes", how long?
2gb
II. Have premises been regularly used? lit Yes 0 No If "yes", how long? 2 '3 V GAte S
Are games of chance being flayed now on these premises or has it ever been? I[ Yes 0 NJIf "yes", give full details.
1-AS! D,4t6' FEbI<UAt2.CI ~ 2010
12. Are the premises or any part thereof / If "yes", slate lhe lype or license and number.
~heregamesofchanc~aretobepl~yed . Yes DNo C L - 000 7 /1 2- //3
licensed by the State Liquor Authonry? L ':L
10. Capacity for public assembly of premises presently owned or occupied.
13. Has such license ever been
revoked or suspended? 0 Yes
~NO
If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
L 8J-GC-2 (Kev. 4/03)
Page I of2
1111/111111111111111111 ~IIII .J
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PART C. PURPOSES OF GAMES
14. State the specific purposes for which the eftire net proceeds are to be devoted and in what ranner.
1/3 ChA Ie,+ A /0 / G + 2.. /:3 0 .,{J15~A- (lo;J..s
I I
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,
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 ofthe license,
the provisions ofthe Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provisions
oflocallicensing 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.
[Q@/IDI8'I/[2M] f? ~ -'1/iX f! C2-AtftJltz,,-kl
Date Signature fHead of ganization Print Name
i"teIlJT~ C~A,./!{t\"';.)
NEW YORK
D ()+C~6-SS
. O~ WArt/NJE~
A \ ex f> C Zfi.rnleLtCJ 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.
STATE
OF
ss
COUNTY
OF
~TOWNr -.p. ....~
~I -
Signed .8J<:)( f C"'2.4 f AI l~ c C:
Commissioner of Deeds
,20~
SANDRA E GRASSY
Notary Public. State of New York
NO.01GR6192375
Qualified In Dutchess Cou
My Commission Expires 0
L BJ-GC-2 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 .J
/r
GC-2A
-,
APPLICATION FOR GAMES OF CHANCE LICENSE
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NYS RACING & W AGERlNG BOARD
1 Broadway Center, Suite 600
Scbenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
GC- UJ] - [1[iliJ -1616121- ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
Usl names, addresses and dates of birth of all officers.
If organization is a eorporatioa, or an inc:orpondcd or uniDCOl'pOlllllld assoc:iaIioa, list offic:ers and directors.
TTJ:!E I NAME, I '\ DATE OF BIRTH STREET ADDRESS
-lJ'66 }4#-A<l:HiJ (b~IiLj.I_I_I_1
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Attach additional sheet if necessary.
[Qli] 1 [Q[1J 1 [ill]
Date
CITY
ZlP
SCHEDULli: 2:
!.\'lEMBERS IN CHARGE OF GAMES
(MUST UST AT LEAST FOUR MEMBERS or APPLICANT ORGANrZATlON)
DA TE YEARS OF
PA')~Jr:J f R- --1, fl~;1 m~Mflr:tli~ ;:tA'~J :~~:I'~J. LII ca:"#1 ';;"0
~(Y\o.v J<Av~"1l __.B_I_j'.I.l.~i 7 -!J-~1ii.tY. AP!f-___ _Jl.~!p~ll (.f -1J:.S"!3
Lf;"," 14", k ,'" --1-' --XlI J'lit, t 2 u · ",,,' u'1r;;' tu, , z J9&
-&.J SA"" 0 ---1 ~ L ~ lJJ.' - 2B A.fL- W!. ' - j ,: --II! I z!;'/ rJ
---,-,-
-,-,-
--- -- ,.--.- ,-
______ ~= I == 1 =
s,"HHlIil.V~: AF'XH f ,\R\'f,\FFlUATR ORGANIZATIONS ASSiS'I'fNC AT GA(\lIDS
/4 ~ JXH _Lt,RIE.S_,'/\Frn!i\'l'L;~_ r ,.."'en ..'\uxn .!.6. I~Y/t"".FFH -fl\., TF j .TSTi::j) ~~ii.
(! ! n\' ~'-' i!:' 1':!
NA!'v1F (W i\\ XOL\.RY!AFFIUATE
<JAMES OF CHANCE ID NU!'v1!3ER
L !U-GL-l.\ ,R.e\. 3;th ~
Page t of 2
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Schedule 1: Officers and Directors
J-OO''t f"' ~~~
WAPPINGER LODGE #2609 OFFICERS for 2U- In9-
Title Name Address
....-.----.----..----.-. ---...----------- --------- ....----..----....-....... --------------- -.- ----..---....
Exalted Ruler
Leading Kgn
LoyalKgn
Lect. Kgn.
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
Trustee
Trustee
Trustee
Trustee
Trustee
\.
Joseph P. Havelka Sr.
Eileen E. Boyer
Diana Cole
Paul Bader
Mark H. Fox
Catherine Rohling
Rosemarie Perretta
Robert M. Acquanlta
Pamela S. Kultsar
Susan Dorler
James Boyer
Rocco Valente
Alex Czarnleckl
Alfred DeRose
Vacant
38 Hickory Lane
134 Andrews Road
P.O. Box 549
134 Andrew~ Road
28 Tiger Road
54 Brothers Road
35 Cathy Road
10 Vorndran Dr.
58 HIllis Terrace
21 Valley Road
134 Andrews Road
61 Flshklll Hook Rd.
31 Hele,n Drive
25 Hickory Lane
No Officer receives compensation of any kind.
Town Zip DOB
....-----...........--...-..---... ..-.. -..-------.. ...--...---.......--..-...
Pawling 12564 11/13/1942
Lagrangevllle 12540 01/02/1943
Hughsonvllle 12537 04/25/1948
Lagrangevllle 12540 09/20/1965
Hopewell Jet. 12533 09/15/1957
Wappinger Falls 12590 04/22/1940
Poughkeepsie 12603 08/07/1943
Wappinger Falls 12590 OS/25/1942
Poughkeepsie 12603 02/01/1950
Wappinger Falls 12590 03/29/1939
Lagrangevllle 12540 11/28/1937
Hopewell Jet. 12533 06/06/1941
Wappinger Falls 12590 10/16/1941
Pawling 12564 1112811961
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all member.; 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
EMBER NAME DATE OF BIRTH MEMBERSH~P fTREET ADDRESS
5 Ec ir-rIJ/utlE'D t--Lf.-r:;l-
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L BJ-GC-1A (Rev. 3106)
Attach additional sheet if necessary.
Page 2 of2
CITY
-,
ZIP
1III1III1II .J
Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jct 11 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. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset HlI/ East Fishklll 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 Jct. 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. Fishklll 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wappingers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Kinry Road Poughkeepsie 19 01/17/1933