Septic capacity, and this is the big one. Massachusetts sizes septic systems by bedroom count under Title 5. Any project that adds a bedroom, which includes most additions and effectively every ADU, has to be measured against your system's rated capacity. If the system will not carry the additional load, the project becomes a septic upgrade plus an addition, which is a materially different budget.
Whether this affects you depends entirely on your town, and the variation across Worcester County is dramatic:
Sterling has no municipal sewer anywhere in town. Every property is on private septic, and the Board of Health reviews wastewater capacity before a building permit is issued.
Princeton is almost entirely septic and private wells.
Boylston is mixed, with only a portion of the town sewered.
Holden is partly sewered, with the trunk lines owned and operated by the state Department of Conservation and Recreation.
West Boylston is roughly 85 percent sewered with mandatory connection inside the sewered district.
Shrewsbury is approximately 90 percent sewered, which makes it one of the easier places in the county to build an ADU.
Setbacks, lot coverage, and height. Still apply, and on a tight lot a detached ADU may simply not fit where you pictured it. Your town applies the same dimensional rules it would apply to a single-family home.
The existing foundation. On an attached addition, what you are tying into determines a great deal. Older homes across this county sit on fieldstone and rubble foundations laid by hand, and the connection between old and new is usually the hardest part of the job.
Watershed regulations. If you are in Boylston, Clinton, Holden, Leominster, Paxton, Princeton, Sterling, West Boylston, or Worcester, your property sits in the Wachusett Reservoir watershed, and the Massachusetts Watershed Protection Act regulates land use within critical areas near tributaries, wetlands, and surface water. On most lots it never comes up. Near a stream it can affect where you build and how much impervious surface you add.
Wetlands. Conservation Commission review applies near wetlands in every town, and on the larger wooded lots common in this area it comes up more often than people expect.