Application for Temporary Extension of Premises for Outdoor Dining Page 3 of 3
B.
Identify nearby residences or businesses that may be disturbed by noise or other aspects of the
proposed outdoor dining and describe how you will monitor and minimize such disruptions.
7. APPLICANT’S CERTIFICATION
I, the authorized signatory, hereby submit this application (hereinafter the ‘Application’), to the Worcester License
Commission for approval.
I do hereby declare under the pains and penalties of perjury that I have personal knowledge of the information
submitted in the Application, and as such affirm that all statements and representations therein are true to the
best of my knowledge and belief. I further submit the following to be true and accurate:
1) I understand the requirements of and certify that my establishment will comply with all of the Massachusetts
Mandatory Safety Standards (e.g. workplace and restaurants) in effect as they relate to COVID-19.
2) I understand that any false statement or misrepresentation will constitute cause for disapproval of the
application or sanctions or revocation of the approval.
3) I understand that the licensee's failure to operate the licensed premises in accordance with the rules of the
License Commission, requirements established by the Governor’s June 1, 2020 Order or City Manager’s
June 3, 2020 Order, and applicable laws and regulations may result in sanctions, modifications, or revocation
of the license.
Name of Authorized Signatory (please print/type)
Title (e.g. Property Manager, Attorney, etc.)
8. ATTACH the following documents for your application to be deemed COMPLETE:
Proof of ownership, lease or license rights to utilize the area proposed for Outdoor Table Service.
A completed written COVID-19 Control Plan (State of MA mandatory self-certification form).
Photos of the proposed outdoor dining area(s) and/or alterations proposed.
A plan (neatly drawn sketch) of the proposed outdoor dining area(s) with an appropriate level of detail.
Proof of Insurance: Workers Compensation OR an affidavit that the establishment has no employees.
Proof of Insurance: Liquor Liability – including the extended premises areas (if serving alcohol).
Sidewalk dining only: Complete the supplemental sidewalk dining application and submit with this
application (a separate permit from DPW&P is not necessary).
9.
EMAIL a complete application AND the above required attachments to
OutdoorDining@worcesterma.gov to begin the review process.
Applications must be complete to assure timely review and approval. Applications will be reviewed in the order
they are received. Incomplete applications will cause processing delays.
click to sign
signature
click to edit
![]()
