City of Worcester
License Commission
APPLICATION FOR TEMPORARY EXTENSION OF PREMISES FOR OUTDOOR DINING
(WITH OR WITHOUT ALCOHOL)
Note: This application is to be used only for temporary extensions of outdoor table service during the period in which
applicable COVID-19 Emergency Orders are in effect.
Worcester License Commission
c/o Division of Planning & Regulatory Services
City Hall, 455 Main Street, Room 404, Worcester, MA 01608
E-mail:
OutdoorDining@worcesterma.gov Phone: (508) 799-1400 x 31440 Fax: (508) 799-1406
1. APPLICANT & RESTAURANT INFORMATION
A.
B.
Entity (Restaurant) Name (D/B/A) Legal Name (Individual/Corporation), IF different
C.
Restaurant Address Mailing Address (IF different from restaurant)
D.
Applicant/Applicant’s Contact Name Title (e.g. Owner, Manager, etc.)
Email Address Phone Number
2. LOCATION OF OUTDOOR DINING AREA(S)
A.
Outdoor Dining Area Address Owner Name (IF different)
(IF different from restaurant address)
B. Specify the location(s) of outdoor dining area(s) proposed. Note: Indicate Yes or No for all categories.
Deck
Lawn
Parking Lot
Patio
Sidewalk*
*Note: Supplemental sidewalk dining application is required.
3. ALCOHOL SALES AND CONSUMPTION (ON-PREMESIS)
A. The establishment is currently licensed to serve/pour alcohol on-premises (indicate Yes or No):
B. If yes, describe how the establishment will manage to confine alcohol consumption to the premises:
Application for Temporary Extension of Premises for Outdoor Dining Page 2 of 3
4. DESCRIPTION OF OUTDOOR SEATING AREA(S) AND PREMESIS ALTERATIONS
A.
Proposed Outdoor Capacity
Number of
Seats
Number of
Tables
B. On-site Parking Spaces
Parking
Currently
Parking
Proposed
C.
Provide a description of the changes proposed to the premises including each area identified above.
Attach photos and a neatly drawn sketch of the proposed outdoor areas depicting compliance with the
State’s Mandatory Safety Standards for Restaurants. The sketch must show: table locations and identify
the number of seats per table; perimeter fences; barriers between tables;
locations of directional
signage, signage posted to employ social distancing and hygiene protocols; accessible routes and
seating areas, and all other physical features in the extended premises area. If outdoor dinin
g is
proposed within parking areas, the sketch must also show parking spaces and circulation aisles that
will remain available for parking as well as ingress and egress to the dining area and parking lot. Attach
additional pages as necessary.
B. Describe plans for accommodating patrons during inclement weather:
5. HOURS OF OPERATION FOR OUTDOOR DINING AREA(S)
A. Indicate your proposed hours of operations for outdoor dining.
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours of
Operation
6. GOOD NEIGHBOR PRACTICES
A.
If on-site parking is being reduced, describe transportation options for customer access to the
restaurant.
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.
Signature of Applicant
Date
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.
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